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July 2010 Issue for Perinatal Post

In this issue...

• Diabetes and Pregnancy
• Catheter Associated Blood Stream Infections in the Neonate
• STABLE/NRP
• Update: PQCNC Maternal Health Projects July 2010
• March of Dimes Update
• Upcoming Programs and More

Diabetes and Pregnancy

Most health care providers are aware that the rate of pre-existing diabetes during pregnancy has greatly increased in recent years. The two main reasons for this increase are advanced maternal age and obesity. When taking care of a pregnant woman with pre-existing diabetes, it is important to understand if she has Type I or Type II diabetes. Type 1 diabetes mellitus is characterized by an absolute insulin deficiency. This patient is at risk for the development of ketoacidosis. Type II diabetes is characterized by insulin resistance. These women often require large amounts of insulin during pregnancy to ensure euglycemia.

There are many risks associated with pre-existing diabetes in pregnancy. Among the fetal risks are spontaneous abortion, congenital anomalies (especially neural tube defects, congenital heart defects, and lower limb anomalies), fetal demise, and growth abnormalities (both IUGR and macrosomia). Maternal risks linked to diabetes in pregnancy include diabetic ketoacidosis (DKA), worsening of existing retinopathy and nephropathy as well as increased incidences of hypertensive disorders of pregnancy, pyelonephritis, and polyhydramnios. Women with pre-existing DM should have an ophthalmology examination at least once during their pregnancy.

Dietary management can be a challenge for the pregnant woman with diabetes. It is important for the care provider to remember that pregnancy requires an additional 300 kcal/day. Specific caloric recommendations during pregnancy depend on ideal body weight. A diabetic pregnant woman's diet composition should contain the following: 40% CHO, 20% protein and 30 - 40% fat. She should avoid periods of longer than 4 hours without food intake. Bedtime snacks will decrease the risk of nocturnal hypoglycemia. An example of an appropriate snack would be a medium apple or peanut butter crackers.

Insulin requirements can change significantly over the course of pregnancy. It is often necessary to reduce a woman's insulin dose by 10 - 25% in the first trimester. Doses will then need to be increased as gestation advances. After 35 - 38 weeks, insulin requirements may actually decline.

Surveillance recommendations include close monitoring of maternal blood glucose (at least 4 times daily) and a determination of HgbA1C every 4 to 6 weeks during pregnancy. A normal HbgA1C during pregnancy is 4.0- 5.5. The goals of blood glucose monitoring are as follows: fasting value <95, preprandial < 105, one hour postprandial < 140, and two hour postprandial < 120. Postprandial levels are correlated with fetal growth, birth weight, and neonatal hypoglycemia. Increased fetal surveillance with serial growth scans and twice weekly NST at 32 weeks gestation is also recommended.

The goal for intrapartum management of a woman with diabetes (either gestational or pre-existing) is to maintain maternal blood glucose between 60 - 110 mg/dL. This is necessary to prevent both DKA and neonatal hypoglycemia. One way to accomplish this tight control is with an insulin drip. Subcutaneous insulin dosing during labor can sometimes be difficult to manage due to the patient's npo status for an unpredictable amount of time.

Insulin requirements will decline sharply after delivery. A woman with pre-existing diabetes mellitus will usually require 40 - 50% of her pregnancy dose in the postpartum period. Her pre-pregnancy regimen can be re-initiated after delivery. A woman with gestational diabetes mellitus can discontinue her insulin after delivery, but should have blood glucose monitoring for 48 hours to evaluate her need for continued treatment. Women who have had gestational diabetes during pregnancy are at increased risk for developing diabetes later in life. They should have a 2 hour GTT at their postpartum visit. In addition, they should be counseled that they should be screened for diabetes on a yearly basis for the remainder of their lives.

-- Jennifer Smith MD, PhD, Assistant Professor, Maternal Fetal Medicine, Department of Obstetrics & Gynecology, WFU School of Medicine and Mona Brown Ketner, RN, MSN, Nurse Educator, Northwest AHEC, Wake Forest University School of Medicine.

Maternal Fetal Medicine Telephone Access
Wake Forest University Maternal Fetal Medicine Faculty now offers 24 hour direct access to our Maternal Fetal Medicine attending physicians. This new phone is carried by our Maternal Fetal Medicine faculty members and also has a voice mail option. Please feel free to contact us at any time at 1-877-MFM-9919 if we can be of assistance

-- Heather L. Mertz, MD, Assistant Professor, Maternal Fetal Medicine, Department of Obstetrics & Gynecology, WFU School of Medicine

Catheter Associated Blood Stream Infections in the Neonate

The Perinatal Quality Collaborative of North Carolina (PQCNC); a community of organizations, agencies and individuals committed to making North Carolina the best place to be born. To achieve our aim we commit to collaborating with everyone who shares an interest in improving the health and health care of women of childbearing age and/or infants in our state. North Carolina for too long has ranked in the lowest 10% of US states in infant mortality and far too many North Carolina babies are born sick or before completing 39 weeks of gestation. Using the expertise of families and front line health care providers, together with quality improvement science we will improve the triple bottom line: better outcomes for babies and mothers, better experiences for families when babies are born sick or prematurely and better value for each health care dollar.

One initiative of the PQCNC has focused on an effort to decrease Catheter Associated Blood Stream Infections in the neonate. Thirteen teams from nurseries around the state have joined together with each other and families to decrease the number of Catheter associated infections and promote better outcomes for infants born in North Carolina. With the potential to impact outcomes at every center and improve the health of a large population of North Carolina patients, and with recent support from the Division of Medical Assistance, the goal of the Catheter Associated Blood Stream Infections (CABSI) Initiative is to reduce CABSI by 75% in participating Newborn Critical Care Centers by reducing the number of line days and by standardizing insertion and central line maintenance.

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

STABLE/NRP

With the cut of funding from the state of North Carolina for neonatal and perinatal outreach, you may have noticed some changes related to the educational offering by Wake Forest University Baptist Medical Center. I would like to take this opportunity to update you on some of these changes.

The Neonatal Resuscitation Program (NRP) is designed to teach an evidence-based approach to resuscitation of the newborn through the introduction of concepts and basic skills of neonatal resuscitation. The causes, prevention, and management of mild to severe neonatal asphyxia are carefully explained so that health professionals may develop optimal knowledge and skill in resuscitation. NRP is designed for those who participate in neonatal resuscitation in the delivery room and newborn nursery. Although Pediatric Advanced Life Support (PALS) and Pediatric Education for Prehospital Professionals (PEPP) courses are appropriate for those who participate in resuscitations outside the delivery room, NRP also may be useful to pre-hospital providers who desire in-depth training specific to neonatal resuscitation. Completion of the program does not imply that an individual has the competence to perform neonatal resuscitation. A comprehensive instructional textbook, which includes an interactive multi-media DVD-ROM, forms the basic educational component of the program. NRP is offered through Life Support Education at Wake Forest University Baptist Medical Center. Information regarding a schedule of upcoming classes, course fees, and online registration can be accessed via Life Support Education's website ( http://www.wfubmc.edu/Life-Support-Education). They may also be reached at 336-716-2800.

The Neonatal Resuscitation Program Instructor is often desired by those in the community to assist in the maintenance of provider status for those within their institution. This one day course is designed for the NRP Provider who has demonstrated excellence in NRP concepts and has a desire to achieve instructor status. NRP Instructor courses are offered through Life Support Education as frequently as 4 times a year. Information regarding the NRP Instructor Class schedule is available via Life Support Education's website or by calling 336-716-2800.

The S.T.A.B.L.E Program was developed to meet the educational needs of health care providers who must deliver this important stabilization care. S.T.A.B.L.E. education is critical to the mission to reduce infant mortality and morbidity and to improve the future health of children and their families. S.T.A.B.L.E. is the most widely distributed and implemented neonatal education program to focus exclusively on the post-resuscitation/pre-transport stabilization care of sick infants. Based on a mnemonic to optimize learning, retention and recall of information, S.T.A.B.L.E. stands for the six assessment and care modules in the program: Sugar, Temperature, Airway, Blood pressure, Lab work, and Emotional support. A seventh module, Quality Improvement stresses the professional responsibility of improving and evaluating care provided to sick infants. Any health caregiver involved with post-resuscitation and/or pre-transport care of sick newborns would benefit from the S.T.A.B.L.E. Program Learner/Provider course. Students who complete the S.T.A.B.L.E. Learner Course are awarded a course completion card. The S.T.A.B.L.E. Program is offered by the Brenner Children's Hospital Critical Care Transport Team in conjunction with Northwest AHEC of North Carolina. The program is offered twice yearly and can be scheduled at your institution if interest is present. This can be arranged by contacting Tammy Rush, RN BSN, C-NPT, nurse manager of the Brenner Children's Hospital Critical Care Transport Team at tarush@wfubmc.edu or by phone at 336-713-6444.

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

Update: PQCNC Maternal Health Projects July 2010

The 39 Weeks Project of the Perinatal Quality Collaborative of North Carolina (PQCNC) has been working since last fall to decrease the number of elective deliveries (induction of labor or repeat c-section) done before 39 weeks of gestation due to the increased risk of respiratory complications in babies born too early. Thirty-eight hospitals across North Carolina, representing approximately two-third of the babies born in this state, have been testing strategies to prevent these deliveries from taking place.

Hospitals have been collecting data on every single scheduled delivery from 36 weeks up to 39 weeks of gestation. Most hospitals are reporting a decrease in the number of scheduled deliveries before 39 weeks, especially for inductions of labor. Some hospitals still face challenges in preventing repeat low-transverse c-sections with no other medical complications from being scheduled too early, while others have eliminated this practice altogether. Several hospitals have changed their scheduling procedures or implemented a peer review process for electives cases scheduled before 39 weeks. Outreach to OB offices to inform them of these changes has facilitated the process at some hospitals.

Patient education is an essential component of this project. A study published in December 2009 found that 24% of women believe term pregnancy is between 34-36 weeks, and 51% said 37-38 weeks is full term (i). A paper in the July 2010 edition of Obstetrics & Gynecology suggests pregnancies at 37 and 38 weeks of gestation should be redefined as "early term" because outcomes are not the same from 37 to 41 weeks (ii). The NC chapter of the March of Dimes has been an important partner in this work. They have provided copies of a patient brochure called "Why the Last Weeks of Pregnancy Count" to all hospitals participating in the 39 Weeks Project. Hospitals and physicians report that this has been a helpful tool in explaining to patients why the doctor or the hospital may not allow a patient to schedule a delivery on a specific date, even if it is most convenient for her.

Teams in the 39 Weeks Project will come together for a final learning session in Chapel Hill on August 31. While the initiative is formally ending this summer, participating teams will be able to continue to submit data to PQCNC and receive reports. Because many teams are continuing to make changes, and others want to monitor their data to make sure the hold the gains they have achieved this year, they will continue to track scheduled deliveries at 37 and 38 weeks to ensure elective deliveries are not done at these gestational ages. This is in accordance with the new Joint Commission Perinatal Care measure that went into effect in April 2010.

PQCNC is now preparing for the 2010-2011 maternal health initiative, Supporting Intended Vaginal Birth (SIVB), which will focus on reducing the c-section rate among first-time mothers at term. A letter of invitation will be sent to hospital and OB leadership later this summer, and hospitals will begin "prework" in October 2010. The first learning session for that initiative will take place in January 2011. If you are interested in more information about either PQCNC maternal health project, contact Kate Berrien, RN, MS, 39 Weeks Project Coordinator, kberrien@unch.unc.edu, 919-843-9336.

ⁱ Goldberg RL, McClure EM, Bhattacharya A, Grout TD, Stahl PJ. Women's Perceptions Regarding the Safety of Birth at Various Gestational Ages. Obstetrics & Gynecology 2009; 114: 1254-58.
ⁱⁱ Fleishman AR, Oinuma M, Clark SL. Rethinking the definition of "term pregnancy". Obstetrics & Gynecology 2010; 116:4-6.

Get Involved with the North Carolina Perinatal Association

One of my favorite quotes is, "When spider webs unite, they can tie up a lion". I think this quote is so applicable when I think about the wealth of knowledge and skills we have among the North Carolina Perinatal Association (NCPA) membership. Over the years, North Carolina perinatal providers have united to work on infant mortality reduction efforts, on smoking cessation projects among pregnant women, and on reduction of neural tube defects in Western NC to the lowest rates ever. With this kind of energy and collaboration, we are making great strides in improving the health and wellness of women and children in North Carolina.

The NCPA needs your involvement to continue working on initiatives that improve perinatal health in NC. 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 web! 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.

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.

-- Tara Owens Shuler, M.Ed., LCCE, FACCE, NCPA President.

Is Your Patient Still 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: An Online Tobacco Cessation Course" 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. This Northwest AHEC course is interactive, and includes the 5A approach to counseling along with four case studies.

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

-- Nedra Edwards Hines, MHA and Mona Brown Ketner RN, MSN Northwest AHEC

March of Dimes Update

The state legislative short session officially began May 12, 2010; and there is great concern about a potential increase in infant mortality as a result of devastating cuts made last year. March of Dimes, the NC Child Fatality Task Force, and our partners have come together to ask that there be no further cuts to maternal and child health programs. Bills were introduced by the Senate and House in an effort to protect critical funds. Funding for these vital programs is in both Senate and House budgets, and the conferees are now meeting to create the final budget. March of Dimes held its annual Advocacy Day June 9 and urged legislators to support these funds to prevent infant mortality.

-- Anna Bess Brown, MPH, State Program Director, March of Dimes