Cecilia M. Jevitt

Transition of Adolescents With HIV to Adult Care: Characteristics and Current Practices of the Adolescent Trials Network for HIV/AIDS Interventions

&NA; The transition process from pediatric to adult health care for adolescents with chronic diseases is always challenging and can be even more so for adolescents with HIV disease. The purpose of this study was to describe characteristics and current practices surrounding the transition of adolescents from the clinics of the Adolescent Trials Network for HIV/AIDS Interventions to adult medical care. This report focuses on the processes of transition, perceived barriers and facilitators, and anecdotal reports of successes and failures. Practice models used to assist adolescents during transition to adult medical care are described. Interviews were conducted with 19 key informants from 14 Adolescent Trials Network clinics. Findings revealed no consistent definition of “successful” transition, little consensus among the sites regarding specific elements of a transition program, and a lack of mechanisms to assess outcomes. Sites that viewed transition as a process rather than an event consistently described more structured program elements.

Shoulder dystocia: etiology, common risk factors, and management.

Shoulder dystocia and brachial plexus injury occur in 0.5% to 1.5% of all births. Risk factors for both include maternal obesity, excessive prenatal weight gain, maternal diabetes, protracted labor, and fetal macrosomia. These factors are involved in only about 50% of births complicated by shoulder dystocia or brachial plexus injury. Shoulder dystocia has a low recurrence rate (9.8%–16.7%), although history of previous shoulder dystocia is the most reliable predictor of occurrence. Brachial plexus injury is the most common morbidity associated with shoulder dystocia, but 50% of newborns who present with this injury were not subject to shoulder dystocia at birth. Most brachial plexus injuries are transient, although 5% to 22% become permanent. Shoulder dystocia followed by permanent brachial plexus injury or mental impairment is one of the leading causes of malpractice allegations. Prompt assessment and management of shoulder dystocia and preparation to maximize the efficiency of shoulder dystocia maneuvers are critical. Documentation of the appropriate use of maneuvers to relieve shoulder dystocia demonstrates standard of care practice, thereby decreasing the potential for successful malpractice allegations.

Effectiveness of a discharge education program in reducing the severity of postpartum depression A randomized controlled evaluation study

OBJECTIVE The effectiveness of a hospital discharge education program including information on postnatal depression was evaluated to reduce psychological morbidity after childbirth. METHODS A randomized controlled trial (RCT) was conducted in a regional hospital in Taipei. Two hundred first-time mothers agreed to take part and were randomly allocated to an intervention group (n=100) or control group (n=100). The intervention group received discharge education on postnatal depression provided by postpartum ward nurses. The control group received general postpartum education. The main outcome measure was the Edinburgh Postnatal Depression Scale (EPDS) administered by postal questionnaire at six weeks and three months after delivery. RESULTS Women who received discharge education intervention on postnatal depression were less likely to have high depression scores when compared to the control group at three months postpartum. CONCLUSION A discharge educational intervention including postnatal depression information given to women during the postpartum stay benefits psychological well-being. PRACTICE IMPLICATIONS A postpartum discharge education program including information on postnatal depression should be integrated into postpartum discharge care in general practice.

Screening for Perinatal Depression With Limited Psychiatric Resources

BACKGROUND: The reported rates of perinatal depression range from 10% to 15%. Many communities have limited resources for diagnosis and treatment of depression. OBJECTIVE: The purposes of this descriptive study were to evaluate the feasibility of screening women over time for perinatal depression and making appropriate referrals for diagnosis and treatment. DESIGN: Registered nurses, including community health nurses and a midwife, attempted to screen clients during the prenatal period and at 72 hours and 6 weeks postpartum. The Edinburgh Postnatal Depression Scale was used. RESULTS: Registered nurses were able to screen 180 women at least one time. Based on the initial screen, 63 (35%) women screened positive for depression and had the potential to be referred to a licensed social worker for diagnosis and/or treatment. CONCLUSION: Registered nurses were successful in screening for perinatal depression and making appropriate referrals. Longitudinal screening was difficult due to client refusal to be screened, participants being lost to follow-up, and/or moving outside the designated census tracts. Consistent with the literature, 10.6% of women were diagnosed with a depressive disorder.

Postpartum Stressors: A Content Analysis

A qualitative content analysis was conducted on narratives written by 127 mothers at four to six weeks postpartum. This study aimed to identify and compare postpartum stressors to the Tennessee Postpartum Stress Scale (TPSS). The TPSS is a guide to common postpartum stressors and an instrument to assess postpartum stress. Most participants in this study were white (91%), married (72%), and not working (70%). Eighteen stressor categories aggregated into two themes: Stressors Arising within the Maternal-Newborn Dyad and Stressors External to the Maternal-Newborn Dyad. Sixteen of 20 items on the TPSS were identified in the narratives. No stressor categories outside the TPSS were identified.

Pregnancy complicated by obesity: midwifery management.

Obesity-related comorbidities such as gestational diabetes and hypertension have the potential to affect at least 25% of women in the United States. Midwives have been caring for and collaboratively managing these conditions in nonobese women for decades. Prenatal weight gain advice should be based on pregravid body mass index and aim for the lower end of the 1990 Institute of Medicine prenatal weight gain ranges. Obese women may require extra ultrasound and blood glucose testing during pregnancy. Pregnancy complicated by obesity may limit the place and style of birth. Midwives can integrate management techniques into the perinatal care of women whose body mass indices exceed 29 to reduce risk and future disease for mothers and newborns.

Breastfeeding Status and Maternal Cardiovascular Variables Across the Postpartum

BACKGROUND There have been recent reports that lactational history is associated with long-term womens health benefits. Most of these studies are epidemiological. If particular cardiometabolic changes that occur during lactation ultimately influence womens health later is unknown. METHODS Seventy-one healthy women participated in a prospective postpartum study that provided an opportunity to study anthropometric, endocrine, immune, and behavioral variables across time. Variables studied were heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), C-reactive protein, body mass index (BMI), perceived stress, and hormones. A cohort of women without a change in breastfeeding (N=22) or formula feeding (N=23) group membership for 5 months was used for analysis of effects of feeding status. The data were analyzed using factorial repeated measures analysis of variance and analysis of covariance. RESULTS SBP and HR declined across the postpartum and were significantly lower in breastfeeding compared to formula feeding mothers (p<0.05). These differences remained statistically significant when BMI was added to the model. Other covariates of income, stress, marital status, and ethnicity were not significantly associated with these variables over time. DBP was also lower, but the significance was reduced by the addition of BMI as a covariate. Stress also was lower in breastfeeders, but this effect was reduced by the addition of income as a covariate. CONCLUSIONS These data suggest that there are important physiological differences in women during months of breastfeeding. These may have roles in influencing or programming later risks for a number of midlife diseases.

Shoulder dystocia: nursing prevention and posttrauma care.

Shoulder dystocia is a birth emergency that occurs in approximately 1% of all births. Shoulder dystocia can be followed by broken clavicle or humerus, brachial plexus injury, fetal hypoxia, or death. Although risk factors for shoulder dystocia include previous birth complicated by shoulder dystocia, maternal obesity, excessive prenatal weight gain, fetal macrosomia, gestational diabetes, and instrumental delivery, shoulder dystocia is not predictable. Perinatal nurses can reduce the risk for shoulder dystocia by teaching mothers about optimal weight gain in pregnancy and assisting mothers with diabetes to prevent hyperglycemia through diet management and medication use. During childbirth preparation or early labor, nurses can educate mothers about position changes and maneuvers used for shoulder dystocia. Nurses play a vital role in obtaining assistance during a shoulder dystocia, keeping time, assisting with maneuvers such as suprapubic pressure, and documenting the dystocia management. Nurses can assist mothers and families to review the shoulder dystocia and any newborn injuries in the postpartum period, thereby reducing confusion and anxiety. Regular drills and case reviews help build nursing shoulder dystocia management skills.

Experiences of Antenatal Care Among Women Who Are Socioeconomically Deprived in High‐Income Industrialized Countries: An Integrative Review

INTRODUCTION Socioeconomic deprivation in high-income industrialized countries is a key factor in poor perinatal outcomes. Limited access, utilization, and quality of antenatal care seem to play an important role in poor perinatal outcomes. METHODS This integrative review aimed to explore experiences of antenatal care among women who are socioeconomically deprived in high-income industrialized countries. A search was conducted using 5 databases for articles published from 2004 to 2014. Six qualitative and 3 quantitative articles were selected. These were systematically appraised for quality independently by 3 researchers. Relevant themes were identified and organized into categories. RESULTS The disadvantages experienced in antenatal care by women who are socioeconomically deprived start before the first contact with health care services and are notable throughout the entire pregnancy. There is disparity in choice of medical or midwifery service provision models. Six categories emerged during review: choice of service provision model, feeling valued, various types of discrimination, structural and interpersonal accessibility, comprehensibility and trustworthiness of information, and engagement and sense of responsibility. Categories underscored the importance of the womans relationship with the antenatal care provider. DISCUSSION Antenatal care models with women-centered approaches and continuity of care, such as midwifery models, have potential to increase the satisfaction of women with low socioeconomic status with care; this may increase antenatal care utilization and improve perinatal outcomes.

Symptoms and Signs Associated with Postpartum Thyroiditis

Background. Postpartum thyroiditis (PPT) is a common triphasic autoimmune disease in women with thyroid peroxidase (TPO) autoantibodies. This study evaluated womens thyroid disease symptoms, physical findings, stress levels, and thyroid stimulating hormone (TSH) levels across six postpartum months in three groups, TPO negative, TPO positive, and PPT positive women. Methods. Women were recruited in midpregnancy (n = 631) and TPO status was determined which then was used to form the three postpartum groups. The three groups were compared on TSH levels, thyroid symptoms, weight, blood pressure, heart rate, a thyroid exam, and stress scores. Results. Fifty-six percent of the TPO positive women developed PPT. Hypothyroid group (F (2, 742) = 5.8, P = .003) and hyperthyroid group (F (2, 747) = 6.6, P = .001) subscale scores differed by group. Several symptoms and stress scores were highest in the PPT group. Conclusions. The normal postpartum is associated with many symptoms that mimic thyroid disease symptoms, but severity is greater in women with either TPO or PPT positivity. While the most severe symptoms were generally seen in PPT positive women, even TPO positive women seem to have higher risk for these signs and symptoms.