Loss of Blood Loss of Breast Milk? The Effect of Postpartum Hemorrhage On Breastfeeding Success

CASE STUDIES
Proceedings of the 2013 AWHONN Convention
I Have HPV. Does That Mean That My Husband Cheated

on Me? Answering Women’s Questions About HPV
Women’s Background was answered by the nurse practitioner based on
Health he purpose of this presentation is to edu- evidence-based practice literature. A new onset of
T cate nurses about the most current evidence-
based research findings regarding human
HPV does not necessarily mean that infidelity has
taken place. Research confirms that a healthy im-
papillomavirus (HPV). Many healthcare profes- mune system can clear HPV in 12 to 24 months
sionals are not current on the research asso- from the time of transmission. HPV persistence
ciated with HPV. Thus, they are uncomfortable can occur for up to 10 to 15 years; therefore, it
discussing it with patients. HPV is the primary is possible for a partner to have contracted HPV
cause of cervical cancer, genital warts, and from a previous partner and transmit it to a cur-
cancers of the vulva, vagina, penis, anus, and rent partner. It is also possible the patient’s partner
Aimee C. Holland, DNP,
oropharynx. Most individuals have never heard recently cheated on her; research confirms both
WHNP, FNP, RD, The
University of Alabama about HPV and its association to cervical can- possibilities.
at Birmingham, Birmingham, cer. Cervical cancer is preventable, and it is the
AL responsibility of the healthcare team to empower Conclusion
patients with scientifically accurate information re- Research literature indicates that scientifically cur-
Keywords rent HPV skill-building and informational resources
human papillomavirus
garding HPV prevention.
HPV
are needed to help healthcare providers meet
cervical infection Case the concerns of their patients. HPV research has
sexually transmitted infection A newly married, 29-year-old, White, healthy rapidly progressed; however, public knowledge
patient information female presented to the clinic to obtain her has not kept pace with the scientific advances.
ASCUS/+HPV Pap smear results. Upon receiving Female patients are seeking specific information
Paper Presentation the diagnosis of HPV, with tears in her eyes the pa- about HPV from their healthcare teams. This is
tient responded to the nurse practitioner, “I have why it is important for healthcare professionals,
HPV. Does that mean that my husband cheated including nurse practitioners and nurses, to stay
on me?” The patient was educated about trans- informed about the most recent and scientifically
mission, clearance, and risks of HPV. Her question accurate HPV research.
Adenocarcinoma: Yes Cervical Cancer Can Still Happen

in Young Women
Amy McKeever, PhD, RN, Background Surprised by this finding, the physician took a
Villanova University, Lafayette orldwide efforts to reduce cervical cancer small biopsy and noted that the patient had always
Hill, PA
Keywords
W have been successful with the development
and implementation of the cervical cancer/human
had all normal cervical cytology screenings. The
healthcare provider was suspicious as it did not
adenocarcinoma papillomavirus vaccine. Success has been noted appear to be a cervical polyp. Pathology returned
cervical cancer throughout the United States in the reduction in adenocarcinoma. The patient was immediately re-
human papillomavirus squamous cell cervical cancers, those that ac- ferred to the gynecologic oncology practice. Upon
count for approximately 75% to 80% of all cervi- arrival, a full pelvic exam was performed, and
cal cancers. However, the rate of adenocarcinoma the patient was sent for a chest, abdomen, and
Women’s Health has risen, notably in young women of reproductive pelvic CT scan and scheduled for a radical hys-
Paper Presentation age. terectomy. The CT scan revealed a sizable tumor
around her cervix with measureable nodes along
the iliac chain. She underwent surgery, recovered,
Case and began a traditional course of chemotherapy
M.L. is a 24-year-old female who telephoned her for cervical cancer: Paclitaxel and Carboplatin ev-
obstetrician complaining of break through bleed- ery 21 days for six courses. Premedication was
ing on her oral contraceptive pill. While many given with each course and patient was sent home
healthcare providers typically reassure their pa- with antiemetic therapy. The patient did well, com-
tients, this provider brought the patient in for an pleted chemotherapy, and was sent for complete
exam. On exam, the physician discovered a small pelvic radiation as she had residual lymph nodes.
mass protruding from the internal os of her cervix.
JOGNN
S92
C 2013 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org
McKeever, A. CASE STUDIES
Two weeks into the radiation, she telephoned the Conclusion

office with severe abdominal pain. The nurse prac- Adenocarcinoma is a particularly challenging can-
titioner triaged the patient, examined her, and she cer to treat. If not caught early, the disease can
was admitted for dehydration and a CT scan. The spread sporadically in the abdominal and pelvic
CT scan revealed severe lymph node invasion cavity. Typical treatment options for microinvasive
with pelvic seeding. Radiation was stopped and disease are large conization procedures with con-
the patient was placed on palliation second line servative follow-up or hysterectomy. Invasive ade-
chemotherapy of Topotecan for comfort care. Hos- nocarcinoma as presented above has high rates
pice was consulted. of morbidity and mortality.
JOGNN 2013; Vol. 42, Supplement 1 S93

CASE STUDIES
Autonomic What? Care of the Pregnant Patient With New

Paraplegia
Background regimens. Educational materials were compiled to
Childbearing pinal cord injury (SCI) resulting in paraplegia provide information on her multiple medications,
S in pregnancy is rare and alters the function
of multiple organ systems. The obstetric manage-
as well as the pathophysiology, signs, symptoms,
and treatment for ADR. She was initially quite de-
ment and nursing care of these women present pressed over her transfer from rehab and refused
specific challenges requiring a multidisciplinary patient care assistant help. Several primary nurses
approach for maternal and fetal health. were scheduled to facilitate her care. Fetal surveys
showed a normally developing fetus. She pre-
Susan Crafts, MS, RN, Beth Case sented to labor and delivery (L&D) at 31.5 weeks
Israel Deaconess Medical
A 24-year-old G2P0 patient was transferred to with signs of preterm labor and concern for ADR.
Center, Boston, MA
our high-risk antenatal unit at 29-week gestation Her blood pressure remained normotensive and
Renee Pustizzi, BSN, BIDMC, from a rehabilitation facility. Her history indicated she returned to antepartum. At 33.5 weeks, she
Beth Israel Deaconess Medical a gunshot wound sustained at 15 weeks result-
returned to L&D for labor management. She was
Center, Boston, MA
ing in paraplegia at level T3 T4. She had severe given an epidural for prevention and management
Keywords neuropathic pain control issues controlled with of ADR. She had a forceps assisted vaginal de-
spinal cord injury narcotics; neuropathic bowel and neuropathic livery. She was discharged to rehab on postpar-
paraplegia bladder complicated by urinary tract infections. tum day 4. Her infant remained in the neonatal in-
autonomic dysreflexia A Foley catheter was in place with Macrobid for tensive care unit for treatment of prematurity and
high-risk pregnancy
suppression. She was on deep vein thrombosis withdrawal.
Paper Presentation (DVT) prophylaxis. She had been started on Ba-
clofen for increased muscle tone, as well as mul-
Conclusion
tiple medications for gastrointestinal prophylaxis.
There is little current literature on the care of the
She had a history of depression/anxiety and was
pregnant patient with SCI. Nurses serve a cru-
being assessed for posttraumatic stress disorder.
cial role in the facilitation of a multidisciplinary ap-
She was admitted for preterm labor monitoring
proach to care these complicated patients. Under-
and the potential for associated autonomic dys-
standing the chronic medical conditions as well
reflexia (ADR).
as the potentially life-threatening complication of
A multidisciplinary team met multiple times to plan ADR will allow obstetric nurses to provide optimal
and manage her care. She challenged the ob- care to patients with SCI during pregnancy and
stetric nursing staff with unfamiliar rehabilitation delivery.
Peripartum Cardiomyopathy: A Multidisciplinary Approach

Kendra L. Folh, RN, BSN, Background complaints of sudden onset dyspnea, cough,
Children’s Memorial Hermann eripartum cardiomyopathy is a rare life- and lower extremity edema. After evaluation and
Hospital, Houston, TX
Keywords
P threatening cardiac condition of unknown eti-
ology that occurs in previously healthy women
chest x-ray revealing pulmonary edema and car-
diomegaly, the patient was transferred to a med-
peripartum cardiomyopathy during the peripartum period and up to 5 months ical intensive care unit at a tertiary care center.
multidisciplinary safety rounds postpartum. Because of the rarity of the disorder, On admission, the patient presented with tachy-
SBAR communication limited practical experience of most clinicians can cardia at 121 bpm, dyspnea with 36 breaths per
lead to delayed diagnosis resulting in higher rates minute, blood pressure 131/89, and SPO2 95% on
of complications and even death. Heightened sus- 2 L nasal cannula. During the obstetric consulta-
Childbearing picion of clinicians is imperative when patients tion, the patient was diagnosed with preeclamp-
sia and transferred to labor and delivery for
Paper Presentation present with signs and symptoms of heart failure,
and utilization of multidisciplinary collaboration is induction of labor and magnesium sulfate ad-
essential to improve clinical outcomes. ministration. During the course of induction, the
patient continued to rapidly decompensate de-
Case spite administration of Lasix, oxygen (O2 ), and
A 30-year-old multiparous female at 38-week ges- unremarkable lab findings with SPO2 of 85% on
tation, without significant medical history, pre- 15 L O2 , heart rate of 140, and respiratory rate
sented to a suburban emergency room with of 40 with bilateral course crackles and stridor.
S94 JOGNN, 42, S92-S110; 2013. DOI: 10.1111/1552-6909.12188 http://jognn.awhonn.org

Zambrana, L. CASE STUDIES
Obstetric safety rounds were held including ma- days after delivery to be followed by outpatient
ternal fetal medicine, anesthesia, and obstetrics cardiology.
at which the nurse expressed concern regard-
ing the patient’s status and symptoms of car- Conclusion
diac failure. This led to escalation of care to It is essential for all clinicians to recognize early
include cardiology consults. Echocardiography symptoms of cardiac failure in the pregnant pa-
revealed left systolic dilated dysfunction and an tient. The establishment of multidisciplinary care
ejection fraction of 25% to 30%. The patient was and obstetric safety rounding is an essential el-
diagnosed with peripartum cardiomyopathy, mag- ement to expediting treatment and care of these
nesium was discontinued, and additional Lasix patients. Nurses have a primary role in early as-
administered. The patient had a spontaneous sessment and participation in the multidisciplinary
vaginal delivery and was immediately transferred team approach to improving patient outcomes and
to a cardiovascular intensive care unit (CVICU). expediting care. The situation, background, as-
In the CVICU she responded to treatment with sessment, recommendation communication tool
BiPap, diuretics, nitrates, beta adrenergic block- enables the bedside nurse to properly commu-
ers, and ACE inhibitors. She was discharged 5 nicate patient status.
OB Hemorrhage Complicated by DIC: Are You Ready?

Laura Zambrana, BSN, Background hematocrit was 16.6; the patient’s starting hemat-
RNC-OB, C-EFM, Baylor his presentation addresses the management ocrit was 32.3.
University Medical Center,
Dallas, TX T of a patient admitted to Baylor University Med-
ical Center’s labor and delivery sustaining mas-
In the OR, the patient was noted to have further
deteriorating vital signs and oozing was noted
Keywords sive hemorrhage with resulting disseminated in-
obstetric hemorrhage
from previous puncture sites. The patient was in-
travascular coagulation (DIC) and peripartum hys-
maternal mortality tubated by anesthesia. Lab work from a hemosta-
terectomy after an induction of labor and forceps
safety sis profile revealed DIC. For the next 2 hours
assisted vaginal delivery. Prompt recognition,
extensive resuscitation with cryoprecipitate, fresh
timely intervention, and a collaborative multidisci-
frozen plasma, blood, and platelets were admin-
plinary team approach were required to save this
Childbearing istered in an attempt to correct the DIC, preserve
patient’s life.
the patient’s uterus, and return her to a hemostatic
Poster Presentation Case state. Continued bleeding was noted and the de-
A 35-year-old healthy female, primigravida at 40 cision was made by the physician to proceed with
1/7 weeks gestation was admitted for oxytocin in- a hysterectomy. Following hysterectomy, the pa-
duction of labor. The patient required a low forceps tient was transferred to the intensive care unit in
assisted vaginal delivery for persistent occiput stable condition.
posterior position and delivered a healthy male,
weighing 8lb 7oz. Following the repair of a third- Conclusion
degree midline episiotomy and bilateral sidewall Massive hemorrhage is a leading cause of ma-
lacerations, the patient had an initial estimated ternal death. Prompt recognition, timely, effective
blood loss of 800 ml, with a firm fundus and vaginal communication, and rapid response are crucial for
packing left in place for a noted friable posterior positive outcomes. Case review and debriefing led
wall. Over the next hour, after the vaginal packing to quality action items being identified. Simulation
was placed, the patient’s mean arterial pressure training has played a key role in quality improve-
showed a significant drop from 89 on admission ment initiatives. The ability to activate a massive
to 52. Fluid resuscitation was initiated utilizing Lac- transfusion protocol was crucial in the above case.
tated Ringer’s solution and Hespan, and 2.5 mg of Simulation scenarios and in situ drills have been
Methergine was administered. Continued bleed- developed through which multidisciplinary collab-
ing was noted and the patient was taken to the oration allows identification and improvement in
operating room (OR) for further evaluation. A stat processes without harm to patients.

CASE STUDIES
Postpartum Psychosis: What Happens When the Bough

Breaks?
Background name and would not eat or drink. At one point, the Judith E. Stoltz, BSN, RNC,
ostpartum psychosis is the most severe type patient cried that the voices were telling her to kill RNIII, Christiana Care Health
P of postpartum psychiatric illness. It can occur

as early as 2 to 3 days after delivery but is more
her infant. A psychiatric consult was done imme-
diately, and a stat head computed tomography
System, Newark, DE
Keywords
common in the first 2 to 4 weeks postpartum. The scan, metabolic profile, thyroid stimulating hor- postpartum psychosis
incidence of postpartum psychosis is 1 to 2 per mone, rapid plasma regain, and 1:1 sitters were
1,000 women. Risk factors identified are history of ordered. Antiagitation medications were ordered.
bipolar illness or depression, family history of men- Results of above tests were normal. A multidisci- Childbearing
tal illness, sleep deprivation, stress, poor support plinary team of social work, psychiatry, nursing,
systems, and low self-esteem. Early diagnosis and obstetricians, and pastoral care worked to ad- Poster Presentation
treatment are crucial for obtaining a positive out- dress this patient’s symptoms and needs. Six days
come for both mother and infant. post cesarean, the patient was transferred to a pri-
vate inpatient psychiatric facility for 2 weeks. The
Case patient then was treated as an outpatient with reg-
A42-year-old G7P3 was admitted at 41 weeks ular office visits.
for a stat cesarean for fetal distress. A previous
history of depression and two other psychotic
episodes existed. The patient had a 9lb healthy Conclusion
infant daughter, who she was breast feeding. The Early identification and treatment of postpartum
husband stayed with his wife and daughter and psychosis is imperative for the well-being of the
other children visited. On day 3, the patient walked mother and to help establish her ability to care for
out of the bathroom with a blank stare, got into her infant and resume her normal activities. Early
bed and started a rocking movement, clutched and excellent nursing intervention and care were
blankets to her chest and sang church hymns in crucial in ensuing this patient’s return to a produc-
a loud voice. The patient would not respond to tive role as a wife and mother.
Expect the Unexpected During Pregnancy

Background tients and allows for case plans to be implemented Gina M. Scott, BSN, RNC-OB,
he birth of a child is a joyous occasion that for complex patients. The first case was a G6P4 Christiana Care Health System,
T parents and family anticipate. Though most

parents plan even the smallest details of their de-
inpatient with a known placenta increta/accreta. A
care plan was established outlining surgical, ob-
Hockessin, DE
Dianne Holleran, BSN, RNC,
liveries, most do not give a second thought to plan- stetric, and nursing responsibilities, but even the Christiana Care Health System,
ning for medical complications during the labor best strategies cannot prevent complications. The Newark, DE
and delivery process. This happy occasion can second case involved a G1P0 who became preg- Keywords
change to one of fear as unforeseen complica- nant through in vitro fertilization. Labor went as placenta accreta placenta
tions arise, and the mother’s life is threatened. Pa- expected, with an uncomplicated vaginal delivery increta
tients need support, education, and a multifaceted of an infant girl, but when the placenta would not pregnancy complications
approach. Emotions such as fear can cloud pa- separate, a placenta accreta was suspected. The
tients’ thoughts and affect decision making. Edu- last case was a G3P2 with a known placenta pre-
cation needs to come from a calm knowledgeable via; the scheduled cesarean took an unforeseen Childbearing
team that is protective and supportive for each turn as a placenta accreta became apparent.
individual.
Poster Presentation
Conclusion
Case Doctors and nurses worked side by side to solve
Three cases presented at our 7,000 delivery level each complication as it arose. Individually these
III labor and delivery room in the past year, allow- three women had specific complications and hur-
ing for case plans to be established. The expertise dles to overcome, but the outcome for each be-
of the maternal fetal medicine staff and the neona- came similar as they all were discharged from the
tal intensive care unit perinatologists attracts pa- hospital to care for their infants.

Banner, S. and Crossan, D. CASE STUDIES
Massive Transfusion Protocol: Saving Our Patients Lives

Amy Dempsey, MSN, RNC, Background intensive care unit (ICU), and spiritual care per-
Exempla Lutheran Medical ostpartum hemorrhage remains the single sonnel responded.
Center, Arvada, CO
Keywords
P most significant cause of maternal death
worldwide. It occurs in 2% to 6% of women who
After intubation in the OR, the patient continued to
hemorrhage. The decision was made to proceed
postpartum hemorrhage deliver vaginally. It can occur early (<24 hours
with a hysterectomy. A massive transfusion proto-
massive transfusion protocol after birth) or late (>24 hours and <6 weeks af-
DIC col was initiated with the blood bank to facilitate
ter birth). The primary cause of early postpartum
Code White preparation and thawing of blood products. Dur-
hemorrhage is uterine atony, and it is typically de-
ing the surgical procedure, the patient developed
fined as >500 ml blood loss following vaginal de-
ventricular tachycardia, and a Code Blue was acti-
livery, >1,000 ml following cesarean, or a 10%
Childbearing vated. Additional interdisciplinary team members
decrease in hematocrit (HCT). Interventions for
from the emergency department, pharmacy, and
Poster Presentation postpartum hemorrhage include treating the un-
ICU responded. At this time, the patient’s HCT
derlying cause and managing the symptoms with
dropped to 21.9, fibrinogen <60, PT = 40, INR
medications, surgical interventions, placement of
= 4.15, and arterial blood gas pH 6.97. During the
uterine tamponade devices, and blood volume re-
surgical case, the patient received 11,440 ml fluid
placement. Improved outcomes are seen with co-
and 11 units PBRC, 7 units fresh frozen plasma,
ordinated team efforts and established hospital
3 units of platelets, 4 units cryoprecipitate. Her
processes.
DIC stabilized and her heart rhythm returned to
Case sinus tachycardia. She remained intubated and
A 45-year-old, G4P1 presented to labor and de- was transferred to ICU. The following day she was
livery in early labor at term. On admission her extubated and transferred to postpartum and she
HCT was 39.9. Her labor was augmented, and was discharged home on postoperative day 4. The
she progressed quickly and delivered vaginally. patient is now a spokesperson for the community
Following delivery of her placenta, she began blood bank.
to hemorrhage. The patient was treated in the
delivery room with fundal massage, Misoprostol,
Hemabate, placement of Foley catheter, and Bakri Conclusion
balloon. Anesthesia and a second obstetrician To efficiently manage massive postpartum hemor-
were consulted and a disseminated intravascular rhage, early treatment must be initiated, interdisci-
coagulation (DIC) panel and two units of packed plinary teams should be utilized, and in this case
red blood cells were ordered. The patient became our massive transfusion protocol was activated.
symptomatic and was transferred to the operat- Coordination of care with the blood bank was crit-
ing room (OR). A Code White was called and an ical to receive the necessary blood products in a
interdisciplinary team of obstetricians, laboratory, timely manner.
Mirror Syndrome in Pregnancy: Two Patients, One Disease

Sheryl Banner, BSN, RNC, Background Case
Christiana Care Health System, irst described in 1892 by John W. Ballantyne, A patient was transferred to us at 27-week ges-
Hockessin, DE
Dawn Crossan, RN, Christiana
F Mirror Syndrome is a preeclampsia-like dis-
ease characterized by fetal or placental hydrops,
tation for severe preeclampsia but was later
diagnosed with Mirror Syndrome. The patient
Care Health System, Newark, maternal anemia, edema, hypertension, liver dys- complained of flu-like symptoms lasting 3 days,
DE function, and poor fetal outcome. It is called Mir- headache, and decreased fetal movement. Signs
Keywords ror Syndrome because the maternal pathology and symptoms included hypertension, oliguria,
Mirror Syndrome mirrors that of the fetus. This is a rare condition proteinuria, pitting edema, and abnormal lab val-
preeclampsia whose etiology is not known. Some of the poten- ues. Acute right-sided abdominal pain developed
ascites tially critical maternal sequelae of Mirror Syndrome during transfer. The pregnancy was known to
hydrops include pulmonary edema, adult respiratory dis- be complicated by hydrops, ascites, and multi-
tress syndrome, pericardial effusions, and renal ple fetal anomalies thought to be incompatible
failure. with life. She was treated with magnesium sul-
Childbearing fate, antiemetics, narcotic pain control, and intra-
venous hydration. A 24-hour urine collection and
Poster Presentation pregnancy-induced hypertension labs were initi-

CASE STUDIES
ated. A magnetic resonance imaging (MRI) scan A stillborn female infant with multiple anoma-
and a surgical consult were ordered to rule out ap- lies, generalized edema, and ambiguous geni-
pendicitis. The MRI verified mild anasarca within talia was delivered weighing 3 pounds 2 ounces.
the abdomen and pelvis, but the appendix was Magnesium sulfate continued postpartum for 24
not adequately visualized. hours. The postpartum course was unremarkable,
and the patient was discharged 48 hours after
The 24-hour urine had nearly 5 grams of pro-
delivery.
tein. The patient became increasingly uncomfort-
able with bilateral 3+ pitting edema from her feet
through her thighs. Induction was recommended Conclusion
due to worsening maternal status, and the po- Careful evaluation is needed to differentiate be-
tential for other morbidities associated with Mir- tween preeclampsia and Mirror Syndrome be-
ror Syndrome. Fetal paracentesis of 600 ml was cause the maternal morbidity may be more
performed to facilitate vaginal breech delivery. extensive.
An Unusual Case: Testing for Fetal Trisomy Abnormalities

in Maternal Blood at 33-Week Gestation
Background pected, so prenatal diagnosis for confirmation Sheryl Banner, BSN, RNC,
n 1997, the detection of fetal deoxyribonucleic of diagnosis was recommended. Transabdominal Christiana Care Health System,
I acid (DNA) in maternal circulation suggested

the future of noninvasive prenatal testing. It is es-
chorionic villi sampling (CVS) was attempted but
unsuccessful because only maternal cells were
Hockessin, DE
Deborah Harvey, BSN, RNC,

timated that 95% of all women opt for prenatal obtained. A relatively new procedure to test the Christiana Care Health System,
screening. Reasons may include the desire to pre- maternal blood for fetal DNA to detect aneuploidy Boothwyn, PA
pare for the birth of an affected child; prepara- abnormalities was considered a solution. Ultra- Keywords
tion for the possibility of an in utero or neonatal sound indicated a single umbilical artery, cleft fetal DNA
death; planning for the time, mode, and place of lip, abnormal kidneys, absent bladder, and rocker trisomy
delivery; planning for specialists to care for the bottom feet. The patient was counseled regarding fetal anomaly
affected child; and options for termination. Inva- the significant risk of neonatal death in the case of
sive tests carry a risk of injury to the fetus and trisomy 18 but insisted on full resuscitative mea-
are not 100% accurate. Fetal DNA testing for ane- sures and a cesarean section for fetal distress. Childbearing
uploidy has been reported to have 98% to 99% Ironically, she had a Category I fetal monitor strip,
specificity. and the biophysical profile score was 2/10. Kary- Poster Presentation
otyping of the newborn indicated Turner Syndrome
Case and trisomy 16.
Our patient was transferred to us at 33-week ges-
tation when an ultrasound detected anhydram-
nios. Genetic testing was offered multiple times Conclusion
due to known fetal anomalies, but she declined. This was our first encounter with transabdominal
Amniocentesis was no longer an option secondary CVS and fetal DNA testing in maternal blood. We
to anhydramnios; however, trisomy 18 was sus- are interested in the impact on the future.
An Unusual Case of Infectious Endocarditis in Pregnancy

Background in patient care management, such as antibiotic Kimberly Francis, RNC,
nfectious endocarditis during pregnancy is treatment, timing of delivery, and timing of cardiac Christiana Care Health System,
I rare, occurring in an estimated 0.006% of
pregnancies. Right-sided endocarditis is most
surgery if required. Wilmington, DE
Dina Viscount, MSN, CNS,
commonly associated with heart and valvular RNC-OB, Christiana Care
Case Health System, Newark, DE
diseases, whereas left-sided endocarditis is as- A 30-year-old G4P1 at 26 5/7 weeks gestation
sociated with intravenous (IV) drug use. Maternal was transferred to labor and delivery from an-
mortality rates are high (33%) due to complica- other facility with a 2-week history of fever, chills,
tions of heart failure and embolic events, and fe- nausea, vomiting, and cough. Her medical history
tal mortality rates are between 14% and 33%. In- included, methicillin-resistant Staphylococcus au-
fectious endocarditis presents unique challenges reus, Hepatitis C, anemia, and IV drug abuse

Dexter, S. V. and Hooper, J. CASE STUDIES
Keywords in combination with methadone use, preliminary placement and oxygen support. During week 3,
pregnancy positive blood cultures, and multiple social issues. she was stable enough for transfer to the inpatient
bacterial endocarditis An echocardiogram, electrocardiogram, and lab- antenatal unit for continuing treatment with antibi-
valvular vegetation
septic emboli
oratory studies were obtained. Consults to in- otics. The patient signed herself out of the hospital
fectious disease, cardiology, and maternal fetal on day 26 against medical advice.
medicine were placed and an antibiotic regime
The patient returned for induction of labor at
was initiated. Shortly after arrival, the patient’s res-
Childbearing piratory status significantly declined. The surgical
37-week gestation secondary to complex antena-
tal course and cholestasis of pregnancy. She de-
Poster Presentation critical care team was consulted and the patient
livered a live born female infant and had a bilateral
was taken for a computed tomography scan and
tubal ligation complicated by a wound infection af-
then transferred to the critical care unit. On day 3
ter discharge. The infant was discharged to home
of admission, she was transferred to the obstetric
as a well newborn.
high-risk area where her course was complicated
by further febrile episodes, septic pulmonary Conclusion
emboli, a right-sided pleural effusion requir- Infectious endocarditis rarely develops during
ing thoracentesis, and subsequently chest tube pregnancy. Treatment requires collaboration be-
placement, multiple antibiotics, blood transfu- tween many disciplines and careful consideration
sions, peripherally inserted central catheter line of the effects on the mother and fetus.
A Case Study of Placenta Percreta and Small Bowel

Obstruction in Pregnancy
Sheryl V. Dexter, BSN, MSA, Background was scheduled for cesarean and hysterectomy
RNC-OB, Inova Fairfax lacenta percreta is a rare and potentially life- at 32 weeks. A multidisciplinary team including
Hospital, Falls Church, VA
P threatening complication of pregnancy. Its in-
Janet Hooper, RNC, BSN, MA, cidence has been increasing and is reported to
the patient’s obstetrician, gynecologic oncologist,
maternal fetal medicine specialist, neonatologist,
LCCE, Inova Fairfax Hospital be one in 533 deliveries. Risk factors include his- anesthesiologist, interventional radiologist, repre-
Women’s Services, Falls tory of previous cesarean/scarred uterus, placenta sentative from blood bank, clinical nurse special-
Church, VA ist, and managers from labor and delivery and the
previa, history of manual extraction of placenta,
Keywords multiple pregnancies, dilatation and curettage, en- operating room met and planned for the delivery.
placenta percreta dometriosis, high parity, and advanced maternal At 31-week gestation, the patient’s pain worsened
abnormal placenta adherence age. Intestinal obstruction in pregnancy is rare and and her hemoglobin and hematocrit dropped. The
small bowel obstruction occurs in one in 3,000 deliveries. Symptoms are patient delivered a viable infant girl via repeat ce-
abdominal adhesions
often nonspecific, and fetal and maternal mortal- sarean the patient went to the intensive care unit
high-risk pregnancy
ity rates are higher during pregnancy as diagnosis (ICU) for recovery and the infant was admitted
can be delayed due to symptoms mimicking typi- to the neonatal ICU. The postpartum course was
cal pregnancy-associated complaints. Significant significant for fluctuating blood pressure that was
Childbearing morbidity or mortality is associated with both com- treated intermittently with medications. The patient
Poster Presentation plications. Concern for fetal outcomes while man- was discharged home on postoperative day 7.
aging these two complications raises therapeutic,
ethical, moral, and social dilemmas. Conclusion
The presence of two rare complications necessi-
Case tated extensive planning for the anticipated deliv-
A 32-year-old multigravida with a history of ex- ery and well-being of the mother and infant. Sig-
tensive adhesions of the small bowel into the an- nificant lessons learned from this case included
terior abdominal wall and significant hemoperi- education and support for nursing staff on a va-
toneum was admitted at 28-week gestation for riety of diagnoses uncommon to daily obstetric
sudden sharp abdominal pain, nausea, and ele- practice and a multidisciplinary team approach
vated blood pressure. The fetal heart rate was 147 to care. Daily high-risk multidisciplinary planning
and a Category I strip. Routine and pregnancy- rounds and strong collegial relationships that fo-
induced hypertentions labs were within normal cused on the patient and infant’s welfare facilitate
limits. Sonogram and MRI showed a small bowel evidence-based care of critically ill mothers and
obstruction and placenta percreta. The patient infants.

CASE STUDIES
Loss of Blood = Loss of Breast Milk? The Effect

of Postpartum Hemorrhage on Breastfeeding Success
Background caused her hemoglobin to drop from 12.6 mg/dl to Lydia Henry, MSN, RNC-OB,
ostpartum hemorrhage (PPH) can trigger a 6.8 mg/dl. She was transferred to a high-risk unit CCE, IBCLC, Christiana Care
P series of events that prevent a mother from

fully breastfeeding. Routine evidence-based ac-
and transfused. Breastfeeding was interrupted for
the next 22.5 hours while the infant was formula
Health System, Newark, DE
Stephanie P. Britz, BSN,
tions to increase breastfeeding success become fed. When reunited, the infant nursed strongly for RNC-OB, CCE, IBCLC,
interrupted. Mother and infant may be sepa- 40 minutes but was not satisfied. At this time, a Christiana Care Health System,
lactation consultant informed mother of the risk Newark, DE
rated, causing a delay in breastfeeding initiation.
Maternal fatigue may also necessitate formula of delayed onset of copious milk production. A Keywords
supplementation. A traumatic birth and maternal collaborative team of nurse, patient, and lactation postpartum hemorrhage
stress and fatigue associated with PPH often in- consultant initiated a plan to stimulate the mother’s delayed lactogenesis II
terfere with the normal onset of lactogenesis II. full lactation potential, which eased the mother’s insufficient milk supply
Blood loss and hypotension may cause ischemia anxiety over potential insufficient milk supply. The
or infarct of the highly vascular pituitary gland. mother was taught signs of ineffective breastfeed-
During lactogenesis II, prolactin, which stimulates ing and delayed milk onset prior to discharge Childbearing
human milk production, releases from the anterior and referred to breastfeeding support resources.
pituitary. Following pituitary insult, altered prolactin The mother noted breast changes at 8 days. At
Poster Presentation
levels likely cause insufficient milk production. In 2 weeks old, the infant regained birth weight, and
the rare complication of Sheehan’s Syndrome, the formula supplementation decreased. At 1 month,
necrotic pituitary completely loses function result- the mother elected to use occasional formula, but
ing in failure to lactate. Insufficient milk and de- was feeding the infant at breast to her satisfaction.
layed onset of milk production, consequences
of PPH, can have a significant impact on new Conclusion
mothers who often identify low milk supply with Nurses can collaborate to offer appropriate practi-
failure. cal and emotional breastfeeding support for moth-
ers experiencing PPH. Even when full breastfeed-
Case ing is not attained immediately, evidence supports
A primipara delivered vaginally a large for gesta- the possibility of transitioning from partial to full
tional age infant who nursed strongly for 25 min- breast milk feeding. Mothers who experience PPH
utes within the first hour. The mother’s initial blood need nurse champions to support their breast-
loss of 300 ml and a subsequent bleed of 850 ml feeding goals during this precarious time.
Seckel Syndrome and Pregnancy: The Importance

of a Multidisciplinary Team Meeting
Background and was developmentally delayed. She was re- Sue Ellen Abney-Roberts,
eckel syndrome is an extremely rare autoso- ferred to our Academic Medical Center for prena- MSN, RNC, C-EFM, Georgia
S mal recessive genetic disorder that is a form

of primordial dwarfism and was first described in
tal care at 23-week gestation. Of note, the patient
was 3 ft 10 in. tall and weighed 71 pounds at her
Health Sciences Medical
Center, Augusta, GA
1960 by Dr. Sekel. Typically, intrauterine growth initial visit. A referral was made to the ear, nose, Frankie Parks, BSN, RNC,
restriction is first identified in utero with a subse- and throat (ENT) clinic due to a history of respira- Georgia Health Sciences
tory arrest during general anesthesia as a child Medical Center, Augusta, GA
quent diagnosis of dwarfism. Physical features as-
sociated with this syndrome are microcephaly and requiring a tracheostomy. Septal deviation was Keywords
unusual facial features, including large eyes, a noted with complete obstruction on the right. Her Seckel syndrome
narrow face, micrognathia, and a protruding nose cesarean under regional anesthesia was sched- multidisciplinary
similar to a bird’s beak. These physical features uled, and plans were made for an awake intuba- dwarfism
cause a significant anesthesia risk. Patients may tion if general anesthesia was required. She could
have varying degrees of mental retardation. open her mouth 0.5 cm preoperatively.
Childbearing
The patient presented to labor and delivery (L&D)
Case at 35 and 36 weeks to rule out labor. Nursing was Poster Presentation
The patient was a single 24-year-old G1P0 with unaware of this high-risk patient and was con-
Seckel syndrome. She lived with a family member cerned about plans for her delivery. After these

Koch, J., Hodge, Z. T. R., Watson, M., and Hooper, J. CASE STUDIES
triage visits, a plan of care for delivery, includ- eratively then was transferred to the ENT unit on
ing obstetrics (OBs), ENT, and anesthesia, was day 2 after the tracheostomy was decannulated.
placed in her chart by maternal–fetal medicine. The mother and infant were discharged on post-
Unfortunately nursing was not included in de- operative day 3.
velopment of this plan and therefore no plans
were made for her postpartum care with a tra- Conclusion
cheostomy, a skill none of our staff was comfort- This is an example of the importance of hav-
able with. The patient arrived for a clinic visit at ing nursing representation when multidisciplinary
37 4/7 weeks gestation in active labor and was plans of care are being established for high-risk
sent to L&D. She gave birth in the adult operat- OB patients. Care planning for high-risk patients
ing room under general anesthesia with an awake should include potential complications of postpar-
tracheostomy prior to the cesarean. The patient tum care including possible ICU admission and
went to medical intensive care unit (ICU) postop- training for staff.
Pregnancy Following a Spinal Cord Injury: Inpatient

Management of a Paraplegic Patient
Judith Koch, RN, Inova Fairfax Background complexity of headaches with visual changes. Her
Hospital, Sterling, VA pproximately 20,000 American women be- blood pressures were elevated on admission. She
Zahira Tamara Rachel Hodge,
MSN, FNP-BC, RN, Inova
A tween the ages of 16 and 30 live with a spinal
cord injury (SCI), and of those women 14% will
had a history of an SCI at T9 and T10 following a
motor vehicle accident resulting in spastic para-
Fairfax Hospital, Falls Church,
become pregnant at least once during the course plegia. Preeclampsia was ruled out however, the
VA of their lifetimes. Though pregnancy can still en- patient remained hospitalized due to the complex
Martha Watson, RN, MSN, sue following an SCI, the risk for maternal and ob- nature of her condition and increased risk for falls.
Inova Fairfax Hospital, Falls stetric complications is profound, and these preg- The patient had a spontaneous vaginal delivery at
Church, VA nancies are often deemed as high risk. Normal 32-week gestation.
Janet Hooper, RNC, BSN, MA, physiological changes of pregnancy can exacer-
LCCE, Inova Fairfax Hospital bate neurological symptoms, further impede mo-
Women’s Services, Falls bility and overall independence, and attribute to Conclusion
Church, VA circulatory problems. Deep vein thrombosis, pro- Management of this patient focused on preven-
gressed muscle weakness and sensory impair- tion of further neurologic deterioration, optimiza-
Keywords
ment, urinary incontinence, bowel incontinence or tion of mobility, emotional support, prolongation
spinal cord injury
paraplegia constipation, bladder infections, autonomic dys- of pregnancy, and maintenance of maternal and
multidisciplinary reflexia are only a few of the maternal complica- fetal well-being. This required a multidisciplinary
pregnancy tions that can occur. Obstetric complications are team, including Perinatology, Neonatology, Neu-
maternal included but are not limited to preterm labor usu- rology, Physical Therapy, Occupational Therapy,
fetal Nutrition, Social Work, and Nursing. Interventions
ally resulting in early delivery and premature rup-
ture of membranes, which pose potential health included daily rounds with the medical and nurs-
risks for the neonate. Proper management of such ing team to discuss the status of the mother and in-
Childbearing patients requires collaboration among various dis- fant. Daily education of the nursing team occurred
to address specific care needs related to the pa-
Poster Presentation ciplines and most importantly education of the patient’s diagnosis. Daily assessment and communi-
tient, family, and/or caregivers.
cation to anticipate the patient’s needs were com-
Case pleted by the multidisciplinary team. In turn, the
A 28-year-old patient, G1PO, was admitted at collaborative efforts set forth by all members of
26-week gestation for rule out preeclampsia. The the healthcare team attributed to safe and effec-
patient presented with an increased severity and tive patient care and a positive outcome.

CASE STUDIES
Second Shift Holiday Neonatal Code: A Recipe for Stress

Background a timely fashion from the newly initiated neona-
bstetric and neonatal staff felt extremely frus- tal code box and their roles during the resuscita-
Newborn O trated and stressed during a neonatal resus-
citation. Frustration and tension among code team
tion. Additional staff were required to assist. The
nursing supervisor and respiratory staff were not
Care members affected communication and the team’s initially present during the code because the over-
effectiveness. head code announcement was not initiated.
Case
Melody Wireman, MSN, RNC, A 31-year-old multigravida presented via ambu- Conclusion
CNS, APN, BayHealth Medical
lance to labor and delivery at a community hospital Multiple interdisciplinary debriefings were held to
Center, Dover, DE
with spontaneous rupture of membranes of muddy gather information and to support staff involved
Robin Lynn Underwood, MSN, amniotic fluid at 8 cm dilatation. The patient was in the code. Nursing/physician leadership iden-
RNC, CNS, APN, Bayhealth flailing her arms and legs uncontrollably, compro- tified system/process issues from these debrief-
Medical Center, Dover, DE
mising the accuracy of maternal and fetal heart ings. Strategies were developed to reduce staffs’
Ruth Elizabeth (Sue) Haddad, rate assessments. Initial fetal heart tones were in frustration, tension, and feelings of chaos, includ-
MSN, RNC-OB, BayHealth the 50 seconds and the maternal pulses were ing reassignment of code team member respon-
Medical Center, Dover, DE palpated in the 70 seconds. The obstetrician sibilities, implementation of routine code drills that
Keywords was notified immediately. A male infant born via included staff from all shifts and all team member
neonatal codes spontaneous vaginal delivery was limp and cyan- departments, and the initiation of timed neona-
team effectiveness otic. The neonatal intensive care unit (NICU) staff tal code box drills to increase code box familiar-
Poster Presentation was notified. Unique nursing challenges during ity. Staff assisted in developing a code checklist
this code included door-to-delivery time 13 min- that facilitated communication during and after a
utes, unassisted RN delivery, nightshift holiday neonatal code.
with limited staffing, patient presented alone, and
Staff felt more confident in their roles and re-
physician call-to-arrival-time 30 minutes with no
sponsibilities as code responders. Team members
in-house obstetric physician presence.
felt more effective, less stressed, and better pre-
The neonate required compressions, intubation, pared for the unexpected. Empowering staff and
multiple epinephrine doses, and fluid boluses dur- increasing knowledge does decrease frustration
ing the 23-minute code. The team was frustrated and tension during unanticipated and challenging
at their inability to locate emergent supplies in neonatal codes.
You Say Goodbye and I Say Hello

Kim L. C. Petrella, RN, Background alized care was applied to this complex patient.
Christiana Care Health hen nature intervenes in an unusual way by At 22 5/7 weeks, twin A went into severe fetal dis-
Services, Newark, DE
W giving and then taking at the same time, the
Gina M. Scott, BSN, RNC-OB, role of the nurse is to provide skilled nursing care
tress. The family stood by the decision to allow twin
B to mature. At 26 weeks, the patient started run-
Christiana Care Health and support. ning an elevated temperature and the decision for
Services, Hockessin, DE an urgent cesarean was made. Staff from the labor
Barbara Dean, BSN, RNC, Case and delivery room and neonatal intensive care unit
Christiana Care Health A G3011 patient pregnant with twins presented (NICU) were assembled and a cesarean was per-
Services, Elkton, MD to triage at 22 weeks with bleeding. Ultrasound formed. Twin A, a boy, was born stillborn and twin
showed a subchorionic bleed with decreased fluid B, a girl, was born screaming and fighting. Time
Keywords
bereavement to twin A, a boy. Twin B, a girl, looked good. The was spent preparing twin A for presentation to the
premature twins patient was admitted to our high-risk unit until de- parents while twin B was stabilized. Both infants
multidisciplinary team livery ultrasounds continued to show bleeding and were seen and held by both parents. A nationally
approach increased fetal distress. The family was faced with trained local photographer captured a picture of
a decision: should they think about a stat cesarean the sister holding her brother’s hand in the NICU
at 24 weeks if twin A went into severe fetal dis- shortly after birth, and it became the only picture
Newborn Care tress and risk the life of twin B? Should they wait the family had of their twins together. Clergy from
Poster Presentation knowing that twin A would most likely die but give both parent’s faiths visited and customs were ob-
twin B a better chance for survival? A multidisci- served. A memorial service was held in the hospi-
plinary, multifocused team approach of individu- tal chapel where more than 150 attended.

Hayman, R. L. and Henry, L. CASE STUDIES
Conclusion lence. Multiple departments came together to sup-

This experience of caring for a complex patient port this family.
highlighted teamwork and hospital wide excel-
Supporting Mothering Through Breastfeeding

for Incarcerated Women
Deborah Allen, MSN, RNC, Background incarcerated or the benefits of breastfeeding in
IBCLC, Virginia ore than 1 million women are under the con- this population.
Commonwealth University
Health System, Richmond, VA M trol of the criminal justice system, represent-
ing the fastest growing group of prisoners. Women Case
Brenda Baker, PhD, RNC, serving prison sentences most commonly have A mother from a local jail delivered a term newborn
CNS, Virginia Commonwealth been convicted of drug-related offenses followed at an urban medical center. Collaboratively the
University Health System, healthcare team, mother, father, and guards cre-
by nonviolent crimes. It is estimated that 8% to
Richmond, VA
10% of women entering prison are pregnant. A ated a breastfeeding and pumping plan support-
Keywords disproportionally large number of women in prison ing the mother’s desire to breastfeed. The newborn
breastfeeding have a history of physical or sexual abuse, sub- was discharged with the father who would pick up
incarcerated stance abuse, and are mothers of minor chil- breast milk daily from the jail to feed the newborn.
pregnancy The jail agreed to allow the mother to pump in her
dren. Statistics indicate the average prison time
for women is 12 months; therefore, on average, cell and store milk in the medical unit refrigerator.
pregnant prisoners spend 6 to 12 months in prison At 10 days of age, the newborn’s nutritional needs
Newborn Care after the birth of a child, a critical time period in were met with expressed breast milk.
Poster Presentation the mothering experience.
Conclusion
For incarcerated women, pumping and storing
Breastfeeding offers immunological, developmen- breast milk is a simple and uncomplicated way to
tal, and psychosocial benefits to mother and promote maternal–infant attachment and improve
infant. Additionally, breastfeeding contributes to health for mother and infant. Nurses working with
positive maternal self-image and development mothers who are incarcerated have the opportu-
of maternal–infant relationship. Currently, little is nity to change the mothering experience for incar-
known about the experience of mothering while cerated mothers and their newborns.
Help Wanted: Champions for Breastfeeding Success

in Newborns With Ankyloglossia
Rebecca L. Hayman, BSN, Background for the necessary medical evaluation and possible
PCE, IBCLC, Christiana Care nkyloglossia refers to a tethered frenulum that intervention.
Health Services, Newark, DE
Lydia Henry, MSN, RNC-OB,

A restricts the movement of the tongue or lips.
When too restrictive, the newborn may ineffec- Case
CCE, IBCLC, Christiana Care tively suckle at the breast. Breastfeeding difficul- In one case, a second time mother concerned
Health System, Newark, DE ties such as long periods nursing or damaged over her newborn’s tongue-tie status informed
nipples may indicate treatment, and referrals can the maternity nurse that despite intending to fully
Keywords
ankyloglossia be made to pediatricians and surgeons. Histor- breastfeed her first child, she did not reach her
frenulectomy ically, formula gained popularity in the United goal. The first child had difficulty latching, was not
tongue tie States due to cultural influences. Frenulectomy satisfied with a feed, and lost excessive weight.
breastfeeding difficulty was not needed to enable sucking on a bot- A painful latch resulted in bleeding nipples. The
breastfeeding nurse suspected ankyloglossia, however, the pe-
tle. The procedure was viewed as unnecessary
trauma for the newborn. However, for many in- diatrician opted for delay in surgical intervention
fants, breastfeeding can be preserved only with hoping the tongue “would come out on its own.”
Newborn Care timely treatment of ankyloglossia. Parents should The doctor recommended formula bottles to rest
Poster Presentation be educated about their options and have their the nipples initially. During breastfeeding attempts
decisions supported. A team approach with lacta- several times over the next 2 months, the first in-
tion consultants can empower nurses to champion fant lost weight. Finally, she was referred to an oral

CASE STUDIES
surgeon, but by this time, the disappointed mother surgeon. A frenulectomy was performed within
had given up hopes of breastfeeding and ceased 24 hours of the newborn’s birth. The mother breast-
her efforts. fed immediately after the bedside procedure and
continued successfully breastfeeding her son.
In contrast, with her second child, the mother’s
concerns were acknowledged by the maternity Conclusion
nurse who had gained knowledge of ankyloglos- Recognizing that a tight frenulum affects breast-
sia from the hospital-based lactation consultant. feeding allows nurses to collaborate for timely
The nurse instructed the mother on breast pump- breastfeeding interventions. Involving an interdis-
ing and ordered an early lactation consult. Upon ciplinary team can maximize breastfeeding suc-
confirming ankyloglossia with a digital exam, the cess. Nurses can ensure that all mothers reach
consultant collaborated with the nurse for early their breastfeeding goals by championing new-
intervention. This time, the pediatrician ordered borns whose ankyloglossia prevents them from
an immediate, in-hospital evaluation by an oral effectively nursing.
There’s Nothing Sweeter Than Mom’s Own Milk

Background cian ordered formula supplementation; however, Kathryn Rollins, BSN,
he labor and delivery (L&D) nurse’s role is vital the mother stated her desire to continue giving RNC-OB, Baylor University
T in achieving excellence and safe passage for

the exclusively breastfeeding mother–infant dyad.
breast milk to correct the hypoglycemia. I taught
the mother how to hand-express colostrum and
Medical Center, Dallas, TX
Keywords
Infants remaining skin-to-skin during the first 1 to spoon feed the infant, and 35 ml of colostrum was breastfeeding
2 hours of life achieve self-latch, self-regulate successfully expressed and spoon fed to the in- hand expression
blood glucose levels, and have longer breast- fant. The repeat blood glucose was 52. The pedia- spoon feeding
hypoglycemia
feeding relationships. Recent literature and Joint trician was notified of the results using the mother’s
safe passage
Commission recommendations indicate that one expressed breast milk. The infant remained on the
formula feed affects the infant. However, current hypoglycemia management guideline, but did not
hospital guidelines continue to support the use of require formula supplementation or IV glucose.
formula and intravenous (IV) glucose to correct Mother and infant were able to exclusively breast- Newborn Care
infant hypoglycemia. feed for the duration of their hospital stay. This suc- Poster Presentation
cessful scenario of treating infant hypoglycemia
Case with the mother’s expressed milk was well received
As an experienced L&D and trained breastfeed- by my hospital’s neonatology and lactation depart-
ing support nurse, I assisted a new mother ments, as well as hospital management, thus gen-
facing such a challenge. A 28-year-old primi- erating new teaching projects surrounding hand
gravida delivered vaginally at 39 3/7 weeks. Labor expression and spoon feeding.
was complicated by prolonged rupture of mem-
branes and chorioamnionitis. The infant weighed
4,110 grams (9 no. 1oz) and was classified large Conclusion
for gestational age (LGA). The mother intended As nurses, we must strive for excellence in the
to exclusively breastfeed; a successful latch was care of the exclusively breastfeeding mother–
noted. Current hospital guideline requires blood infant dyad realizing that current practices and
glucose to be performed between 1 and 2 hours hospital guidelines must be updated to align with
of life on LGA and sick infants. Initial blood glu- recent research and Joint Commission recommen-
cose results were 34, with immediate repeat of dations. By utilizing current evidence surrounding
28. Per hospital guideline, blood glucose levels a mother’s expressed breast milk, we can ensure
less than 36 require physician notification, infant successful breastfeeding for the long term as well
feeding of 10 ml/kg of formula, and administra- as increase the mother’s confidence that she can
tion of IV glucose. Upon notification, the pediatri- provide for her infant’s needs.

Britz, S. P. and Henry, L. CASE STUDIES
Beyond the Typical: One Mother’s Unique Challenge to

Continue Providing Breastmilk for Her Special Needs Baby
Debra A. Otto, BSN, RN, CCE, Background ing breastfeeding advice. She shared her infant’s
IBCLC, Christiana Care Health reastfeeding is the undisputed optimal feed- history, which was significant for severe gastroin-
Kathryn E. Low, BSN, RN,
B ing method for infants. In response, Healthy
People 2020 called for an increase in the num-
testinal (GI) symptoms since birth, including blood
in stool, vomiting, and fussiness. When MB was
CCE, IBCLC, Christiana Care ber of infants who are breastfed at 1 year to exclusively breastfeeding, she was able to con-
Health Services, Newark, DE 34.1%. The Centers for Disease Control and Pre- trol his symptoms with maternal diet elimination.
Keywords vention reported the breastfeeding rate for 2012 With the introduction of solid foods however, the
breastfeeding as only 25.5%. To accomplish the breastfeeding symptoms returned. With the help of her pediatri-
breast milk goal of Healthy People, mothers need excellent cian MB was able to determine and eliminate the
medications breastfeeding support throughout the entire first offending foods. At the time of the call, MB was suf-
year. In 2005, the American Academy of Pedi- fering from mastitis and was placed on an antibi-
atrics recommended that infants breastfeed ex- otic, which seemed to be triggering the same GI
Newborn Care clusively for 6 months and should continue breast- symptoms for her infant. Faced with the prospect
Poster Presentation feeding for at least 1 year as complimentary foods of pumping and discarding her milk until the com-
are added. Studies have shown an overwhelm- pletion of the antibiotic treatment, she was calling
ing number of infant health benefits associated for advice. The lactation consultant was able to re-
with breastfeeding, including protection of the search this otherwise safe medication and devise
infant from bacteremia, diarrhea, respiratory tract a feeding plan with MB. It was paramount to feed
infection, necrotizing enterocolitis, otitis media, the infant when the concentration of the medica-
urinary tract infection, late-onset sepsis in preterm tion in MB’s milk was at its lowest to minimize the
infants, type 1 and type 2 diabetes, lymphoma, infant’s symptoms.
leukemia, Hodgkin’s disease, and childhood obe-
sity. The more breastfeeding support a mother re-
ceives, the more likely she will be able to offer
these benefits to her child. This support is even
more important when a mother faces challenges Conclusion
that put her at risk for breastfeeding cessation. The implementation of this creative feeding plan
allowed MB and her infant to continue breastfeed-
Case ing with minimal GI disturbances. MB was ex-
The mother (MB) of a 9-month-old infant called tremely happy to be able to continue providing
the lactation resource line at our institution seek- the optimal nutrition for her infant.
Supporting the Lactation Needs of Mothers Facing Perinatal

and Neonatal Loss
Stephanie P. Britz, BSN, Background of breast milk can contribute to creating positive
RNC-OB, CCE, IBCLC, reast milk, long recognized as the optimal memories.
Christiana Care Health System,
Newark, DE B food for newborns, has immeasurable ben-
efits to both mom and infant. However, in cases
Overwhelming grief often accompanies the loss
of an infant. In addition, some grieving mothers
Lydia Henry, MSN, RNC-OB, of anticipated perinatal or neonatal loss, breast
CCE, IBCLC, Christiana Care experience unexpected breast changes that ac-
milk is not usually considered in the plan of care.
Health System, Newark, DE company lactogenesis II. Addressing lactation is-
As hospital-based lactation consultants, who are
sues immediately postpartum should be routine
Keywords also practiced labor and delivery nurses, the au-
care aimed to decrease discomfort and distress.
Perinatal/neonatal loss and thors have been challenged by colleagues who
breast milk
These mothers also have options regarding lac-
are not supportive of the use of breast milk for
lactation suppression tation other than suppression, such as donating
infants who are likely to die. These well-intended
breast milk donation their breast milk, and should be allowed to make
professionals feel they are acting in the best inter-
informed choices.
est of the family. However, in many of these cases,
the use of breast milk can be a wonderful expe-
Newborn Care Case
rience for the mother and her infant. By creating
Some mothers who have experienced a neona-
Poster Presentation a sense of normalcy in tumultuous times, the use
tal loss call to inquire about donating their breast

CASE STUDIES
milk. These mothers seek to give meaning to their gave her son drops of breast milk, prior to his
loss experience and to honor their children. Infor- death.
mation regarding this option should be provided
with knowledgeable guidance. Not all mothers will Conclusion
qualify, and disappointment can be abated if they In difficult loss situations, mothers should still have
are counseled properly. Mothers who have not information about the use of breast milk. Maternity
started to pump must be educated on the commit- and NICU nurses should be familiar with all op-
ment and possibility of stress interfering with milk tions and refrain from making judgments for these
production. Ultimately, praise for offering a selfless families. Lactation consultants can be supportive
act enhances their emotional healing, regardless team members who can assist with the care of
of the outcome. these special patients. Educating the mother who
elects not to use her breast milk should include en-
An example case involving an infant in the neona- gorgement management and the normal process
tal intensive care unit (NICU) involves the phys- of breast involution so she does not encounter un-
ical and emotional comfort of a mother who expected changes alone.
Improving Breastfeeding Outcomes Using Appropriate

Interventions to Champion a Successful Breastfeeding
Relationship for a Mother With Flat Nipples
Background tact and frequent breastfeeding attempts were Kathryn E. Low, BSN, RN,
reastfeeding is the undisputed optimal feed- made. The lactation consultant (LC) or postpar- CCE, IBCLC, Christiana Care
B ing method for infants. In response, Healthy

People 2020 called for an increase in the number
tum nurse taught her how to hand express so that
her infant could receive colostrum. If latch on is
Health Services, Newark, DE
Debra A. Otto, BSN, RN, CCE,

of infants who are breastfed at 1 year to 34.1%. not achieved within 24 hours of life, the patient IBCLC, Christiana Care Health
The Centers for Disease Control and Prevention is educated on breast pump initiation. During this Services, Newark, DE
reported the breastfeeding rate for 2012 as only same time, the patient is taught how to spoon and Keywords
25.5%. To accomplish the breastfeeding goal of finger feed her newborn. After discharge, the pa- breastfeeding
Healthy People, mothers need excellent breast- tient follows up with outpatient lactation services. flat nipples
feeding support throughout the entire first year, es- If the newborn is still unable to latch on and lac- interventions
pecially when faced with difficulties. Studies have togenesis II has not yet occurred, the mother was
shown an overwhelming number of infant health taught how to use nipple shields and a supple-
benefits associated with breastfeeding, including mental nursing system (SNS). The mother was fol- Newborn Care
protection of the infant from bacteremia, diarrhea, lowed by her pediatrician and outpatient LC. Once Poster Presentation
respiratory tract infection, necrotizing enterocoli- this mother achieved full milk supply, the SNS was
tis, otitis media, urinary tract infection, late-onset discontinued. Soon after, attempts were made to
sepsis in preterm infants, type 1 and type 2 di- wean from the nipple shield. At 5 weeks postpar-
abetes, lymphoma, leukemia, Hodgkin’s disease, tum, the infant was exclusively breastfeeding with-
and childhood obesity. The more breastfeeding out any interventions.
support a mother receives, the more likely she will
be able to offer these benefits to her child. This
support is even more important when a mother
faces challenges, such as flat nipples, that put
her at risk for breastfeeding failure.
Conclusion
Case All mothers with flat nipples who are experienc-
In a typical case, a first time mother with flat ing breastfeeding difficulties should be given the
nipples had difficulty with her infant successfully same opportunity to use every evidence-based
latching on to the breast. Initially, skin-to-skin con- resource available to them.

O’Bryant, A. R. and Haedicke, R. A. CASE STUDIES
Whose Baby Is It? An International and Intrafamilial

Surrogate Case Study
Professional Background prior to hospitalization to determine custody and
hough statistics are inconsistently reported, decision making authority.
Issues T existing data demonstrate a dramatic in-
crease in surrogate births. Medical literature
We created a birth plan to direct staff in manag-
ing care for both families. It specified individual
contains many articles about the ethical and
roles in the case, identified who would be present
legal issues associated with surrogacy. The Amer-
for the delivery, separated the preregistration and
ican College of Obstetricians and Gynecologists
admitting process, payment accounts, and con-
(ACOG) has guidelines on surrogate motherhood
Lisa R. Cavin-Wainscott, MSN, sent forms for surrogate care and infant care. It
for physicians, and the American Society of Re-
APRN, RNC-LRN, CPST, outlined data for inclusion on the infant’s identifi-
Olathe Medical Center, Olathe, productive Medicine has guidelines for patients. cation bands, crib card, and birth certificate and
KS However, little information is available for nurses
how to unlink the electronic medical records of
and other healthcare providers to guide care in
Keywords surrogate and infant after copying delivery data.
the hospital setting. Many hospital policies do not
surrogacy
address surrogacy or are not flexible enough to The intended parents came to the United States
gestational carrier
surrogate birth address variations that likely exist in these com- specifically for the scheduled cesarean birth and
adoption plex cases. returned to their home country 1 month later. They
assisted reproduction stayed in a hospital room while the infant was hos-
pitalized and fed expressed breast milk from the
Paper Presentation Case surrogate. Nurses couldn’t match the milk to the
A gestational carrier was identified prenatally baby per our usual procedure, so we allowed the
when scheduling a maternity preadmission ap- two families to pass expressed milk directly be-
pointment. The intended mother was the surro- tween them. Postdischarge infant care was estab-
gate’s aunt and the father of the infant was the lished while the family stayed with local relatives,
aunt’s husband. Department representatives from pending completion of legal documents.
patient registration, accounting, preadmission, le-
gal, and care coordination met with the Director Conclusion
and Clinical Nurse Specialist of the obstetrics de- Creating a plan prior to admission helps alleviate
partment. We identified questions, concerns, and stress and questions regarding a complex case
resources and developed an action plan to obtain and keeps patient care the priority. Familiarity with
solutions for the issues. We contacted the Office of state laws and hospital policies regarding surro-
Vital Statistics and attorneys for the surrogate and gacy and adoption is extremely helpful in being
intended parents. Legal documents were shared prepared.
A Multiagency, Multidisciplinary Approach to a Lethal Fetal

Diagnosis
Angela R. O’Bryant, MSN, Background Case
RN, Illinois Valley Community diagnosis of trisomy 18 occurs in approx- A 39-year-old multigravida patient presented to
Hospital, Peru, IL
A imately one of every 3,000 live births. The
Rita A. Haedicke, RNC, MSN, devastating news of any diagnosis that is incom-
her routine office visit after a diagnosis of fetal
trisomy 18. The physician wanted the patient’s
CNL, NE-BC, OSF Saint patible with life affects the parents, their families, labor and delivery experience to be well coordi-
Francis Medical Center, Peoria, and the healthcare worker. Though uncommon, nated with the obstetric (OB) nursing department.
IL
lethal fetal diagnosis needs to be dealt with proac- Once the patient and her husband met with the
Keywords tively. An effective perinatal bereavement program OB nurse manager, she realized that the family
pregnancy can be used to work with the family to make a had a knowledge deficit and somewhat unreal-
trisomy 18 plan of care that is realistic and expectant. Once istic expectations for the potential outcome. The
fetal anomalies shared, this plan can be an effective way for nurs- OB nurse manager arranged for the patient and
bereavement
ing, physicians, midwives, clergy, and social work her husband to meet with the perinatal center’s
to create the best of an imperfect scenario for all bereavement manager to discuss a plan of care
involved. that would meet their needs. The plan was then
Professional Issues shared with the obstetrician, the OB staff nurses,
Paper Presentation

CASE STUDIES
the hospital clergy and social service department, Conclusion

and the pediatrician who would be caring for the Despite not having a perinatal bereavement pro-
infant. Despite having a heart rate during labor, gram available at a small community hospital, the
the infant delivered in frank breech position with regional perinatal center’s bereavement program
no heart rate. Per the patient’s request and plan was utilized to create a multiagency, multidisci-
of care made in advance, no resuscitation was plinary approach to the care of a patient with a
performed. The patient was able to spend several lethal fetal diagnosis. Creating a collaborative ef-
hours with the infant and was discharged home fort is essential to assist patients in all aspects
on postpartum day 1. The family was very pleased of care delivery. Communicating the needs of
with all of the planning and care that went into the this patient to all departments involved prepared
delivery of the infant, the postmortem care, and the the healthcare providers to meet and exceed the
compassion displayed by the healthcare team. needs of this family.
When a Friend’s Baby Dies: Empowering Nurses to Balance

Professional and Personal Care
Background that she was a “blessing” to them. She stayed with Kim L. C. Petrella, RN,
everal co-workers were sharing stories, each them for her 12-hour shift and was able to provide Christiana Care Health
S one of them having recently cared for a friend

with a fetal demise. They realized that lessons
care and support during her next shift after their
son was born.
Lesley Tepner, BSN, RNC,
learned during their experiences could benefit Christiana Care Health System,
The third nurse dropped off her son at daycare Newark, DE
fellow nurses. The nurses have found that shar-
and was told that her son’s teacher had not felt the
ing their stories with fellow nurses has provided Melanie Chichester, BSN,
infant move and no heart beat was detected. Upon
education and has been therapeutic for them in RNC, Christiana Care Health
admission to labor and delivery, the teacher asked
coping with their own grief. System, Newark, DE
for the nurse, who then cared for her through labor
Case to delivery of a stillborn daughter. Keywords
perinatal loss
The first nurse was called at home by close family peer support
friends with the news of a 28-week fetal demise grief
Conclusion
and was asked to come to the hospital. Her pres- storytelling
It is always difficult to care for a patient with a fe- boundaries
ence as their nurse was requested by the pa-
tal demise but when the nurse knows the patient
tient. She cared for them during her shift and then
on a personal level it adds a layer of complex-
stayed over into the following shift as a support
ity and emotion to the situation. Because of this
person until their daughter was born still.
the nurse should evaluate her effectiveness and
Professional Issues
The second nurse arrived at work and was as- ability to provide quality clinical care to her friend. Poster Presentation
signed a patient with a full-term demise, and the The privacy rights of the patient must also be con-
nurse realized that she knew the patient through sidered and she should be given the opportunity
a church group. The patient and her family did to request another nurse if she is uncomfortable
not object to having a friend care for them, saying being cared for by a person who knows her.
The Birth of Baby Will: Supporting a Devout Catholic

Couple Through the Birth and Death of Their Anencephalic
Son
Background Because there is no treatment for these infants, Ardath Youngblood, MN,
and the condition is catastrophic and renders the RNC-OB, IBCLC, Hunterdon
nencephaly is one of the most common neu-
A ral tube defects. It occurs early in the devel-
opment of the unborn infant when the neural tube
child without the possibility of ever gaining con-
sciousness, many women choose to terminate the
Medical Center, Flemington,
NJ
fails to close, and according to the Centers for pregnancy when they receive the diagnosis. Susan Duffy, BSN, RNC-OB,
Hunterdon Medical Center,
Disease Control and Prevention (CDC) may affect There are women for whom this is not an option Flemington, NJ
as many as one in 4,000 pregnancies per year. because of their religious beliefs. The Catholic

Pouliot, C. K. and Sanford, N. CASE STUDIES
Keywords Church is one faith group that does not endorse birth to perform extreme unction, recovery in her
anencephaly termination and supports carrying the fetus as patient room with her other children and parents
bereavement close to term as possible without endangering the present to share Will’s brief life, and for memories
cultural sensitivity
mother. and mementos to be made of their time together.
Catholic
Case
K.P. came to us for care during her 4th pregnancy.
Professional Issues Conclusion
She found out she was carrying an anencephalic
Some staff were distressed by the additional dan-
child. Her previous children were all delivered via
Poster Presentation ger they felt the mother was exposing herself to,
cesarean at our hospital, and her physician had
but others were glad to help support this family at
urged her to terminate this pregnancy to spare
this difficult time. We worked with K.P. to arrange
her the possible dangers of another cesarean. She
to fulfill her desires. K.P. has been able to move on
was unwilling to do this because of her faith and
from this experience with the help of counseling,
was praying for a miracle for this child or at least
her faith community, and the feeling that she did
that his life would be honored no matter how short.
the right thing by Will. We learned so much and re-
She approached me about her wishes for Will’s vitalized our Bereavement Committee after caring
brief life, including having her priest present at the for the P family.
Amazing Grace: A Journey of Health, Hope, and Healing

Colleen Karen Pouliot, RN, Background present, and we all grew more anxious and frus-
BSN, Catholic Medical Center, roviding culturally sensitive care poses many trated in finding the best way to care for Grace for
Manchester, NH
Nancy Sanford, RN, Catholic

P challenges, including communication difficul-
ties, unfamiliar customs, family dynamics, and di-
the remainder of her pregnancy. An ethics consult
was obtained and Schwartz Rounds was utilized
Medical Center, Manchester, etary variations. Understanding and accepting the to assist staff with all the emotions surrounding this
NH culture of the patient is as important as under- case.
Keywords standing her health concerns. “Grace” provided
culture us with a beautiful example of that lesson. Grace Conclusion
communication immigrated to the United States from Liberia in A plan of care was formulated by the interdis-
interdisciplinary 2004. She suffered the loss of most of her family ciplinary team that incorporated pastoral care
understanding during the war and her only daughter accompa- services to meet Grace’s spiritual needs. A col-
nied her to their new home. She brought with her laborative model incorporates a partnership be-
many challenges and strengths. tween disciplines and includes knowledge shar-
Professional Issues ing and problem solving, while placing the patient
Case at the center. Three physicians volunteered to be
Poster Presentation Grace came to the clinic at 16-week gesta- on call and attend a vaginal breech birth. With
tion and extensive testing revealed the fetus a known lethal anomaly, it was decided that re-
had multiple life-threatening anomalies. Numer- suscitative measures would be futile and cause
ous clinicians attempted to inform and advise her more harm than good, so we prepared for pallia-
regarding the viability of her pregnancy, but Grace tive care. Pastoral care and a labor and delivery
believed God would not give her an infant with nurse trained in bereavement volunteered to be
a problem, and if the infant was sick she would present at the birth. Despite the difficult situation,
feel sick too. She refused to return to the Mater- Grace later expressed to us that she felt very well
nal Fetal Medicine clinic and declined to partici- cared for throughout her experience. Grace’s jour-
pate in any planning for the birth and care of the ney taught us all lessons in patience, acceptance,
neonate. The team knew a lethal fetal anomaly was and understanding of the human condition.

CASE STUDIES
Let Me Live Long Enough to See My Unborn Child: A

Collaborative Effort to Live the Mission, Vision, and Values
of Our Promise, Individuals Caring for Individuals, Together
Background The patient’s wife was 38 weeks pregnant, with Ellen Gaban, RNC-OB, MBA,
n 2012, a large metropolitan hospital continues plans to deliver their third infant at another hos- Texas Health Plano, Plano, TX
I to support nurses to meet patient and family

goals and significantly make a difference in their
pital closer to home. Nurse A asked if we could
meet her patient’s needs and dying wish. On the
Mary Wells, RN, BSN, Texas
Health Plano, Plano, TX
lives. This was a unique situation where nurses, day of delivery, nurse B volunteered for this as-
Toni Kendall, RNC-MNN,
physicians, managers, and hospital units collabo- signment. A room was chosen to provide ade- BSN, Texas Health Plano,
rated to meet the wish of a dying patient to hold quate space for two beds, infant warmer, cardiac Plano, TX
his unborn child. and fetal monitors, and work areas for two nurses.
Ongoing changes in the plan of care continued Keywords
collaborative effort
as the day progressed. The wife’s preference for
unique situation
Case a female physician was coordinated. Both beds dying patient
The intensive care unit had a cancer patient with were placed side by side to enable husband to dying wish
complications that left him dependent on a large participate in the labor process. Anesthesia and multidisciplinary team
amount of high-flow oxygen. If the oxygen was nursing coordinated to provide adequate com- plan of care
removed for any period of time, his oxygen sat- fort level during advanced dilatation. Nursing pro-
uration would quickly drop to a level not com- vided many words of encouragement as the sec-
patible with life. The patient, family, doctors, and ond stage of labor progressed to the delivery of Professional Issues
nurses looked into all the conventional and non- an infant girl.
conventional methods of treatment and could not Poster Presentation
find any way to reverse this life-ending compli- Conclusion
cation. A plan of care was reviewed concerning After delivery, the infant was placed in the patient’s
measures to prolong his life. He declined to be arms. Nurse A was on duty the day the patient
placed on a ventilator, and he understood that passed away holding his daughter with his wife at
he would die in a short period of time (5-7 days his side. Through a collaborative multidisciplinary
estimated by his physician). Nurse A was as- team effort, members can actively seek ways to
signed to this patient. She was able to develop improve the care they offer to each patient and
a bond with him and influenced this collaborative to utilize each other’s skills to increase quality of
effort. care.

Loss of Blood Loss of Breast Milk? The Effect of Postpartum Hemorrhage On Breastfeeding Success

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CASE STUDIES

Proceedings of the 2013 AWHONN Convention

I Have HPV. Does That Mean That My Husband Cheated

Adenocarcinoma: Yes Cervical Cancer Can Still Happen

Two weeks into the radiation, she telephoned the Conclusion

JOGNN 2013; Vol. 42, Supplement 1 S93

Autonomic What? Care of the Pregnant Patient With New

Peripartum Cardiomyopathy: A Multidisciplinary Approach

S94 JOGNN, 42, S92-S110; 2013. DOI: 10.1111/1552-6909.12188 http://jognn.awhonn.org

OB Hemorrhage Complicated by DIC: Are You Ready?

JOGNN 2013; Vol. 42, Supplement 1 S95

Postpartum Psychosis: What Happens When the Bough

P of postpartum psychiatric illness. It can occur

Expect the Unexpected During Pregnancy

T parents and family anticipate. Though most

S96 JOGNN, 42, S92-S110; 2013. DOI: 10.1111/1552-6909.12191 http://jognn.awhonn.org

Massive Transfusion Protocol: Saving Our Patients Lives

Mirror Syndrome in Pregnancy: Two Patients, One Disease

JOGNN 2013; Vol. 42, Supplement 1 S97

An Unusual Case: Testing for Fetal Trisomy Abnormalities

I acid (DNA) in maternal circulation suggested

Deborah Harvey, BSN, RNC,

An Unusual Case of Infectious Endocarditis in Pregnancy

S98 JOGNN, 42, S92-S110; 2013. DOI: 10.1111/1552-6909.12196 http://jognn.awhonn.org

A Case Study of Placenta Percreta and Small Bowel

JOGNN 2013; Vol. 42, Supplement 1 S99

Loss of Blood = Loss of Breast Milk? The Effect

P series of events that prevent a mother from

Seckel Syndrome and Pregnancy: The Importance

S mal recessive genetic disorder that is a form

S100 JOGNN, 42, S92-S110; 2013. DOI: 10.1111/1552-6909.12199 http://jognn.awhonn.org

Pregnancy Following a Spinal Cord Injury: Inpatient

JOGNN 2013; Vol. 42, Supplement 1 S101

Second Shift Holiday Neonatal Code: A Recipe for Stress

You Say Goodbye and I Say Hello

S102 JOGNN, 42, S92-S110; 2013. DOI: 10.1111/1552-6909.12202 http://jognn.awhonn.org

Conclusion lence. Multiple departments came together to sup-

Supporting Mothering Through Breastfeeding

Help Wanted: Champions for Breastfeeding Success

Lydia Henry, MSN, RNC-OB,

JOGNN 2013; Vol. 42, Supplement 1 S103

There’s Nothing Sweeter Than Mom’s Own Milk

T in achieving excellence and safe passage for

S104 JOGNN, 42, S92-S110; 2013. DOI: 10.1111/1552-6909.12205 http://jognn.awhonn.org

Beyond the Typical: One Mother’s Unique Challenge to

Supporting the Lactation Needs of Mothers Facing Perinatal

JOGNN 2013; Vol. 42, Supplement 1 S105

Improving Breastfeeding Outcomes Using Appropriate

B ing method for infants. In response, Healthy

Debra A. Otto, BSN, RN, CCE,

S106 JOGNN, 42, S92-S110; 2013. DOI: 10.1111/1552-6909.12208 http://jognn.awhonn.org

Whose Baby Is It? An International and Intrafamilial

A Multiagency, Multidisciplinary Approach to a Lethal Fetal

JOGNN 2013; Vol. 42, Supplement 1 S107

the hospital clergy and social service department, Conclusion

When a Friend’s Baby Dies: Empowering Nurses to Balance

S one of them having recently cared for a friend

The Birth of Baby Will: Supporting a Devout Catholic

S108 JOGNN, 42, S92-S110; 2013. DOI: 10.1111/1552-6909.12212 http://jognn.awhonn.org

Amazing Grace: A Journey of Health, Hope, and Healing

Nancy Sanford, RN, Catholic

JOGNN 2013; Vol. 42, Supplement 1 S109