Kathleen Leask Capitulo

Perinatal grief online.

Objective:To describe and interpret the culture of an online perinatal loss group. Study Design and Methods:This qualitative study used ethnography, the study of culture. Methods included participant-observation, review of 447 e-mails, and participants’ feedback about the findings. The setting was online in a perinatal loss listserv consisting of mothers and one grandmother who had experienced a perinatal loss through miscarriage, stillbirth, or neonatal death. In this changing group, there were between 82 to 87 participants from North America, Europe, Asia, and Australia. Findings:The essence of the culture was Shared Metamorphosis. The Internet connected grieving women who otherwise would likely not have met. Participants shared virtual identities, created a community, and brought meaning to their perpetual losses. Their grief was a process of remembrance and memories, and they used symbols to represent the deceased babies; angels were a commonly discussed symbol. For bereaved mothers “life would never be the same,” but joining the community of the perinatal loss listserv meant they would never be alone. Clinical Implications:The culture of online support can link individuals who are geographically distant but share common issues, in this case a perinatal loss. Professionals can use this study to better understand what women experience after a perinatal loss, and what their role can be in validating and supporting these new “mothers of angels.”

Creating patient-focused, family-centered, maternal-child and pediatric healthcare.

Healthcare’s economic challenges, corporate mergers, and technological innovations marked the last decade of the 20th century. Both consumers and providers of maternity care faced dramatic changes in reimbursement, which threatened the quality and scope of care provided to childbearing women, children, and families. For nurses in some institutions, this meant decreases in the number of RNs caring for patients and challenges to meet patients’ needs with the focus on a black bottom line, fiscal profitability rather than on the patient. New York’s Mount Sinai Hospital adopted a philosophy of patient-focused care. This article describes the 5-year journey to redesign a traditional, provider-focused obstetric and pediatric program, into a new patientfocused, family-centered maternal-child healthcare center. The process, opportunities, challenges, and outcomes of this ongoing work demonstrate that a scholarly, data-driven, patient-focused process can result in improved quality, and increased patient and staff satisfaction, while decreasing costs.

THE RISE, FALL, AND RISE OF NURSE-MIDWIFERY IN AMERICA

For most of history, the care of women, particularly childbearing women, has been delivered by healers and health care providers who were women. This article is an overview of the historical, social, political, economic, and philosophic forces that shaped the role of women, especially midwives, who care for childbearing families. As healers and health care providers, midwives (and later, nurse-midwives) have based their practice on the natural process of pregnancy and birth. Their holistic view dominated childbirth until the 18th century, when the existence of midwives began to be challenged by institutions. In the United States, the marriage of midwifery with nursing in the 1920s, followed by the consumer childbirth revolution of the 1960s, gave new strength to the profession of nurse-midwifery. Later, health economics provided additional support for nurse-midwifery practice, with demonstrated reduced costs and improved quality. At the cusp of the 21st century, internal and external political forces have now led to the inclusion of nonnurses in the profession of midwifery in the United States. Despite the ever-changing political, economic, and societal climate, midwives consistently have brought superior outcomes and family-centered caring to their practice and their patients.

Should prophylactic antibiotics be routinely given to a mother before a cesarean birth

infections, and urinary tract infections (National Guideline Clearinghouse, 2013). Prior to the new recommendation from the ACO, antibiotics were withheld until after cord clamping because of the concern that antibiotics transferred to the fetus would mask signs of infection, and fetal exposure to antibiotics may lead to increased newborn colonization with antibiotic-resistant organisms. However, studies of newborns have not shown any deleterious effect. Treatment prior to cord clamping may mean that newborns may have to undergo a more complex workup because blood cultures may not be accurate. However, a thorough pediatric assessment is sufficient to assure proper treatment of a newborn. In a study of 8,668 women undergoing cesarean at Washington University School of Medicine, administering antibiotics prior to cord clamping decreased the infection rate by 50%. A multivariate analysis studying five different variables found that only prophylactic antibiotics significantly decreased the rate of infection (Kittur et al., 2012). The failure to treat a woman undergoing a cesarean with antibiotics prior to birth, unless there is an emergency, where a dose would be given as soon as possible, is a departure from acceptable medical standards. This could lead to complications including endometritis, wound infection, pelvic thrombophlebitis, sepsis, and subsequent sequelae. The antibiotic often chosen is a single dose of narrow spectrum antibiotic such as Clindamycin 900 mg intravenous plus gentamicin 1.5 mg/kg intravenous if the patient is beta-lactam allergic. Although there are many obstetric practices that vary among providers, the decision to administer prophylactic antibiotics to women undergoing cesarean birth prior to clamping of the umbilical cord is the standard of care. Implementation of such a policy will decrease the overall rate of cesarean-related infections without adverse outcomes to mothers and their newborns.

Should there be a limit of one single embryo implanted during an IVF cycle

In the last 25 years, assisted reproductive technology (ART) has been the principal cause of multiple births internationally, with many infertility practices transferring multiple embryos to achieve a higher pregnancy rates after the in-vitro fertilization (IVF) procedure; a direct outcome of this practice is a high incidence of multiple pregnancies and the accompanying complications. Today, the science of fertility has advanced to include a new, highly successful method of single embryo transfer (SET) (Cutting, Morroll, Roberts, Pickering, & Rutherford, 2008). In my opinion, limiting the number of embryos transferred to one or two is the most appropriate practice for infertility services. Complications associated with multiples include increased risks of pregnancy-induced hypertension and eclampsia, gestational diabetes, gastrointestinal disorders, anemia, premature labor, and postpartum bleeding. For the fetus/baby, untoward effects include premature birth, low birthweight, growth restriction, and birth defects such as cerebral palsy (Penn Medicine, 2010). Complications rise significantly as the number of fetuses increases, and increase the economic burden for both families and society, thus negatively impacting quality of life for parents and their babies. There are also ethical challenges with multiple pregnancies, including the practice of pregnancy reduction, usually done with triplets and above. Successful IVF cycles require the harvest of high-quality ovum and sperm leading to high-quality embryos. Therefore, ART practitioners assess and evaluate the woman’s ovarian reserve before starting infertility treatments knowing that higher ovarian reserves lead to higher quality ovum harvests. For the male, semen analysis guides treatment and IVF protocols, and for women, powerful drugs must be taken. Infertility treatments are difficult and costly for couples, and medical management must include addressing anxiety and concerns to optimize physical and psychosocial well-being. New methods using biomarkers to improve IVF outcomes conclude that SETs can be standard (Fisch, Keskintepe, Ginsburg, Adamowicz, & Sher, 2007) to reduce multiple pregnancy rates. Several studies have found that SET for patients younger than 30 years old and double embryo transfer for patients who are 30 or older will result in satisfactory pregnancy rate and low incidence of multiple pregnancies (Shibahara et al., 2007). The rapid advancements in the science of the IVF-ET laboratory have made microstimulation and natural period protocols hot topics in reproductive medicine research. A number of European countries, Japan, and the United States are using SET protocols, either legislated or by medical ART guidelines. These guidelines are not yet followed in China, but are expected to be global as the evidence-based science of IVF reaches practices (Cutting et al., 2008). In countries where the cost of IVF is borne by the government, such as the United Kingdom, Belgium, and Switzerland, SET is the standard by regulation. As ART research improves techniques, SET should become the standard practice in IVF for both couples and healthcare providers (Shibahara et al., 2007).

Should Older Teens and Young Adults With Chronic, Life-Threatening Pediatric Illnesses be Transitioned to Adult Providers and Care Based on Chronologic Age?

age 18, parents or guardians legally make all decisions. Usually these young people have spent much time in children’s hospitals and pediatric-friendly clinics that provided comfort, security, and continuity. Although important and invaluable while they were younger, as the young adult matures they may outgrow care in a juvenile environment. Promoting independence and responsibility for one’s own healthcare is important for psychosocial growth and development. Many adolescents with chronic conditions are at higher risk than peers for unnecessary dependency, developmental difficulties, and psychosocial delay. Successful transition to adult healthcare may help prevent this by enhancing autonomy, increasing a sense of personal responsibility, and facilitating self-reliance (Rosen et al., 2003). In 2002, a consensus statement from the American Academy of Pediatrics (AAP), the American Academy of Family Physicians, and the American College of Physicians-American Society of Internal Medicine described the importance of supporting and assisting transition of adolescents with special healthcare needs into adulthood. However, after more than a decade, implementation of programs to successfully transition chronically ill young adults to adult care in a well-organized successful manner has been poor (AAP et al., 2011). In my opinion, primary care providers and children’s hospital systems should use nurse practitioners to coordinate care for these medically complex young adults. Transition plans should be collaborative and begin early, focusing on providing connectivity and communication with the patient and family, pediatric and adult teams, and all multidisciplinary services. Structured transitions begin by the young adult meeting the new teams and building relationships with them, without suddenly ending lifelong relationships with the pediatric team members. Over time, we can prepare these medically complex patients for a safe transition to adult care to enable them to have autonomy and independence regarding their healthcare and quality of life.

Pro/Con: should children visit patients in an intensive care unit (ICU)?

In 1995, my sister suffered a stroke. The undiagnosed arteriovenous malformation in her brain ruptured, which resulted in paralysis on her right side and a coma for 3 of the 10 days she spent in the intensive care unit (ICU). This was quite a traumatic experience for my family, especially because the doctors gave us no hope of recovery. My sister and my son have a close, wonderful relationship, and I knew that because of this bond he should visit her. However, at the time, children were not allowed in the ICU. This means that children miss out on participating in some of life’s most important teaching moments, observing how families weather storms. By visiting a critically ill patient, the child comes to understand that change has occurred, that family bonds are still strong, and why the family routine and behavior are changing (Borges, Genaro, & Monteiro, 2010). Otherwise, the child is left to fantasize, assume, worry, and even become fearful because reality is hidden and they do not know exactly what to believe. That is why, in my opinion, children should absolutely be allowed in the ICU, on a case-by-case basis. Children are more resilient than we give them credit for, and in certain cases, although momentarily traumatic, an ICU visit may even allow closure if it is a last good-bye of a loved one. Children also often lift and lighten heavy environments, so for the patient and family it may be a very good thing to have a child among them. Nonetheless, ICUs have debated this topic for many years, and currently many have policies in place and strict guidelines to follow if and when children visit the ICU (Ihlenfeld, 2007). In preparing children for visits in the ICU it is necessary to be cognizant of the child’s relationship with the patient. The children should want to visit and not be forced or coerced to do so. It is important to explain and prepare children as best as possible, so that the emotional and psychological effects are lessened. Preparing the child for machines they might see, new smells, sounds they might hear, and other physical attributes that will be present or are particular to the patient’s condition is of the utmost importance. Details such as time limitations should be explained: For example, one may say “Susie, now you can only see your grandmother for 20 minutes. She needs her rest, but she is very much looking forward to seeing you.” Although adults may worry that the ICU experience could be traumatic for the child, just the opposite may be true. One study has shown that children’s fears actually lessened after visiting their loved one in the ICU (Davidson et al., 2007). My experience with my sister resulted in some changes when I returned to the facility where I was the head nurse in the ICU. The visiting hours had been 12 noon–2 p.m. and 5 p.m.–8 p.m.; visitors were allowed in twos for 10 minutes and no children were allowed. After reading the literature and contemplating the human effects of restricted visiting, this changed to a 24/7 visiting hours, and children were allowed to visit. Having gone through the experience from a patient perspective I was able to see the importance of access, support, and just being there to comfort. These changes were made to ensure that the loved ones of the patients could have access to the patient, bring all their support to the patient, and be available to comfort the patient as much as was needed. Decisions always have to be based on what is in the patient’s best interest. This does not change when it comes to children visits. When it is in the patient’s best interest, when families are supportive, and when children are well prepared, an ICU visit can be an excellent life experience for a child. If done well, it can be a most rewarding experience for all and when done exceptionally well, even more so for the patient and child involved. Looking back, I should have made sure that my son be allowed to visit his aunt all those years ago.

Is poverty the root cause of the epidemic of type 2 diabetes mellitus in children

In my opinion, poverty is a major contributing factor to the twin tower epidemic of childhood obesity and type 2 diabetes mellitus (T2DM). Between 1963 and 1970, the rate of obesity among children and adolescents was 4.0%. By the year 2000, the rate almost quadrupled to 15.5% (Bloomgarden, 2004). According to the CDC, in the last two decades the United States has experienced increased rates of T2DM in children and adolescents, with obesity being identified as one of the major contributors. Although childhood obesity is known to be a major risk for the development of diabetes (along with other contributing factors such as eating high-calorie foods, lack of exercise, and family history), poverty plays a key, but often overlooked, role. Studies have shown that older non-Hispanic white children in the 8 to 16 age group in families with low incomes were significantly more likely to be overweight than children in families with high income (Alaimo, Olson, & Frongillo, 2001). People living in the lowest socioeconomic status (SES) categories with less than a high school diploma had an excess risk (2.4 times that of higher SES categories) of diabetes-related mortality (Saydah & Lochener, 2010). The poorest income groups are the ones most likely to be obese and thus at risk for developing diabetes. Food insecurity due to uncertain availability of nutritionally adequate foods and socioeconomic constraints impact families in the lowest SES. Clearly, there is an important link between a family’s income level and a child’s health and well-being. Current strategies to reduce childhood obesity and diabetes recommend raising clinical awareness about the disease, developing standard definitions, and assessing and improving the quality of care among children and adolescents diagnosed with T2DM. Unless we focus on poverty, however, this epidemic will not be alleviated. Awareness of the disease is not enough. Recently New York City has taken a strong policy position in increasing the population’s awareness of foods being ordered in all fast food and other restaurants by requiring that use of trans fats be reduced in restaurant food preparation and that calorie counts on menus must be posted in all food establishments. Yet, New York City still shows a variance of diabetes among different socioeconomic groups, especially among ethnic minorities with less than a high school diploma. It is time to broaden our efforts toward learning how to combat poverty if we are ever going to hope to reduce obesity and diabetes in children. In the 2000 recommendations of the American Academy of Pediatrics, it was suggested that social scientists be integrated into pediatric research because of the complexity of the combined issues of race/ethnicity, gender, and SES on child health status. As the U.S. economic recession pushes more families into unemployment and lower SES, both school lunch programs and emergency food assistance have increased by 18%, highlighting the burden of poverty. Addressing poverty as essential in improving children’s lives and health is crucial. If inequalities in SES cause inequalities in health status, it is our job to change this. As nurses, we need to think beyond the clinical indicators and advocate for changes in socioeconomic policies that will reduce income inequality and thus diabetes and obesity in children.