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January 2010 Issue for Perinatal Post

In this issue...

• Update: Preeclampsia/Eclampsia
• Eliminating Elective Deliveries Before 39 Weeks
• Membership in the North Carolina Perinatal Association
• Help in getting your patients to quit using tobacco
• Upcoming programs

Update: Preeclampsia/Eclampsia

Preeclampsia is a hypertensive disorder of pregnancy, occurring after 20 weeks of gestation. It is defined as a systolic blood pressure of >140 mm Hg -or- a diastolic blood pressure of >90 mm Hg on two occasions at least 4 hours apart, accompanied by proteinuria. Gestational proteinuria is defined as >300 mg/24 hour specimen or >1+ on dipstick. Note that previously used diagnostic criteria of a 30 mm systolic blood pressure increase and a 15 mm diastolic blood pressure increase above baseline no longer apply.

A diagnosis of severe preeclampsia usually includes a systolic blood pressure of >160 mm Hg or a diastolic blood pressure of >110 mm Hg. This is usually accompanied by one of the following: proteinuria of 5,000 mg/24 hours or 2+ on dipstick, urine output of less than 30 cc/hour, platelet count <100,000, elevated liver enzymes, persistent headache, visual/cerebral disturbances, or persistent epigastric pain.

Following the continuum of hypertensive disorders, a diagnosis of eclampsia includes findings of preeclampsia along with seizures - which have no other known etiology.

Magnesium sulfate is not administered to treat hypertension; rather, it is given for seizure prophylaxis. Following is one currently accepted therapeutic practice in the treatment for preeclampsia:

• Initial loading dose of 4 to 6 grams of magnesium sulfate in 100 ml of IV solution administered intravenously over 20 to 30 minutes.
• Continuous intravenous infusion of 2 grams/hour to follow loading dose.
• Maintenance IV therapy of 2 grams/hour. Some women will require infusions of 3 grams/hour in order to maintain effective plasma levels of magnesium. Women with oliguria or impaired renal function may only need 1 gram/hour or less as magnesium is cleared renally. Magnesium sulfate is stable in D5W and LR intravenous solutions.

Appropriate assessments during magnesium sulfate administration include:

• Patellar reflexes.
• Auscultation of breath sounds.
• Counting of respirations. A rate of at least 12 and less than 20 respirations per minute and normal depth are desired. Abnormalities in respirations can be a sign of magnesium toxicity and/or worsening preeclampsia.
• Hourly measurement of urinary output. Urine output should be at least 30 cc/hour. Abnormal urine output is often a sign of declining maternal status and additionally increases a patients risk for magnesium toxicity due to reduced clearance. A Foley catheter is necessary for many patients, especially those with severe preeclampsia, to assure adequate assessment of urine output.
• Patient’s level of consciousness.
• Vital signs, including maternal blood pressure and pulse – along with the FHR.
• Laboratory tests at frequent intervals including CBC, LFTs, and magnesium levels. The frequency of laboratory evaluation will depend on the status of the patient and fetus. The therapeutic range for magnesium sulfate is 4 to 7 mEq/L of serum magnesium. Concentrations greater than 7 mEq/L may result in signs of maternal toxicity.
• Observation for signs of toxicity: disappearance of the patellar reflex, nausea and vomiting, respiratory depression, pulmonary edema, respiratory/cardiac arrest if earlier signs not detected.

The antidote to magnesium toxicity is 1 ampule of calcium gluconate, which should be administered slowly over 10 to 20 minutes.

For patients with preeclampsia, magnesium seizure prophylaxis should be administered intrapartum and for a minimum of 24 hours postpartum as these are the times when eclamptic seizures are most likely to occur. At times it is necessary to administer magnesium longer than 24 hours post delivery if the patient's clinical status is not improving.

Patients with myasthenia gravis, cardiac disease, severe infection, and known sensitivity should not receive magnesium therapy. Other alternatives to seizure prophylaxis should be explored for these patients with preeclampsia.

-- Heather L. Mertz, MD, Assistant Professor of Obstetrics and Gynecology, Section Head, Section on Maternal-Medicine (MFM), Wake Forest University School of Medicine (MFM Phone: 1-877-MFM-9919 to contact an MFM doctor). and Mona Brown Ketner, RN, MSN, Nurse Educator, Northwest AHEC.

Eliminating Elective Deliveries Before 39 Weeks

The 39 Weeks Project, the Perinatal Quality Collaborative of North Carolina's first maternal health initiative, launched in September 2009 with a goal of eliminating elective deliveries before 39 weeks of gestation in North Carolina. In addition to longstanding guidance from ACOG advising against scheduling elective delivery before 39 weeks without confirmation of fetal lung maturity by amniocentesis, several large studies published in 2009 provide the evidence base for this project. These studies emphasize higher rates of adverse neonatal outcomes, including respiratory distress and NICU admission, among babies born by planned elective delivery before 39 weeks, as well as the maternal risk of higher rates of cesarean section when inductions of labor are initiated at a low Bishop Score, or before the cervix is ripe and ready to dilate.

PQCNC is a statewide organization committed to making North Carolina the best place to be born by focusing on improving the quality of perinatal care. Forty hospitals from across North Carolina, representing about two-thirds of all deliveries in the state, are participating in this initiative, from large, urban academic medical centers to rural community hospitals with only one or two obstetricians on staff. All participating hospitals sent a team consisting of at least a physician champion, a nurse champion, and a senior hospital administrator to a full-day learning session where they worked to develop an action plan specific to their site.

These sites have been testing changes that will allow them to reduce or eliminate elective deliveries before 39 weeks. Some teams have looked at changing how they handle the scheduling of inductions and c-sections; for example, some now have a nurse take all calls related to scheduling deliveries or ask the provider's office for detailed information about the case, such as gestational age or indication for scheduling the delivery, at the time the case is scheduled. Others have explored new approaches to scheduling deliveries that include only allowing cases to be posted within 7 or 14 days of the procedure, instead of several weeks in advance, or limiting how many induction or c-section slots are available at a given time. One hospital limits weekday induction slots to only those cases with clear medical indications, with open slots for elective inductions on the weekends or on a waitlist basis only. Some teams have examined documentation strategies, to ensure that the indications for scheduling a delivery before 39 weeks are clear to anyone reviewing the chart, while others are working on standardizing criteria for establishing the gestational age.

All participating sites are collecting data on all inductions and scheduled c-sections they perform on patients at gestational ages between 360 and 386, with the assumption that any scheduled deliveries before 36 weeks are exclusively for clear medical indication. This data, which contains no patient-identifying information, is submitted to PQCNC through a web-based data entry program. In addition to providing individual reports to hospitals about their rates of elective delivery <39 weeks, PQCNC is able to analyze the aggregated data to provide an overview of practice across the state.

One theme that has emerged is the fact that many women and their families are not aware of the potential risks of scheduling delivery too soon. An important partner on this project is the March of Dimes, which has provided thousands of copies of the brochure "Why the Last Weeks of Pregnancy Count" to the hospitals in this collaborative at no cost. Hospitals have distributed these brochures to local obstetric providers, childbirth educators, and health department clinics as a way to raise awareness among patients about the potential risks of scheduling an elective delivery prior to 39 weeks.

This project will end in the summer of 2010. Future learning sessions will focus on how to sustain the gains achieved through this work, the importance of partnerships between obstetrics and neonatology, and the value of including the patient's voice in maternal health quality improvement work. For more information, please contact Kate Berrien, 39 Weeks Project Manager, kberrien@unch.unc.edu, 919-843-9336.

-- Kate Berrien, RN, BSN, MS, State Perinatal Outreach Coordinator and Nancy Chescheir, M.D., PQCNC Maternal Project Director.

Membership in the North Carolina Perinatal Association

Imagine with me that you are in a group that is dynamic, energized, and committed to promoting health and wellness in families across North Carolina! Think of what it looks like when professionals join forces to learn and grow together to improve perinatal care. This is just a glimpse of how it is to participate in the North Carolina Perinatal Association. We are a diverse group of professionals with extraordinary commitment to improve perinatal outcomes in North Carolina.

Maybe you see the perinatal world through the lens of the health department you work for, but come away from this group exposed to the latest hospital updates! Suddenly your ability to prepare your patient for their hospital experience or with the latest procedures available is supported by the latest evidence-based research. On the other hand, it might be just the opposite as you provide care in the hospital setting. What an opportunity and useful investment of your time, to network with the community organizations and resource people that influence perinatal care in North Carolina!

You are the reason we exist. Without you as our membership face in the various places that perinatal care is provided in North Carolina, we are invisible. So, whether you are holding the tiny little babies we wish were not so small, or you are working in maternity clinics helping women prepare for the healthiest outcomes, it is you that we need to keep NCPA visible, strong, and as an advocate for perinatal care in North Carolina. We invite you and your colleagues to join us as we grow our membership into a mighty army.

Membership applications are accepted throughout the year from any health care professional or consumer advocate interested in perinatal health. Membership benefits include lower registration fees for the annual conference, which is scheduled for September 26-28, 2010 in Myrtle Beach, South Carolina, free/reduced registration for upcoming educational web conferences, and news/information updates via our NCPA list serve. Please visit our website to view the 2010 conference brochure and membership application forms.

The future is bright as we have launched a new website in order to add new benefits to our very low cost membership. Please contact Frieda.Norris@carolinashealthcare.org if you have any questions about membership. Our website is www.ncperinatalassociation.org. We are waiting for you to join us! Feel free to email us at info@ncperinatalassociation.org if you have questions or comments.

-- Frieda L. Norris, RN, BSN, LCCE, Carolinas Medical Center - Pineville, 704-650-8142.

Need Help in Getting Your Patients to Quit Using Tobacco?

Tobacco is one of the leading causes of preventable disease and premature mortality in the U.S. today. Healthcare providers can have a tremendous impact on reducing the rates of tobacco use and preventing unnecessary disease and death through tobacco cessation counseling offered to patients. "Counseling for Change" is designed to provide tools to enhance the skills of healthcare providers when counseling for tobacco use including smoking cessation, exposure to second hand smoke (SHS), and the use of smokeless tobacco.

Register for Counseling for Change: An Online Tobacco Cessation Course and learn steps to help your patients kick the habit!

According to the AAMC Physician Behavior and Practice Patterns Related to Smoking Cessation, 2007 Summary Report, Physician advice and encouragement have been shown to increase the number of patients who will attempt and succeed in quitting smoking. Recent studies suggest that physician interventions have the potential to increase long-term abstinence rates to 30% from only 7% among adult smokers attempting to quit on their own. View course, credit, and registration details