While so many businesses are shut down and people are staying at home, there’s one thing that will keep happening no matter what—women are still having babies and need access to safe maternity care during the COVID-19 pandemic.
In this dangerous and uncertain time, we wanted to know what’s going on in labor and delivery (L&D)—at least from one nurse’s perspective.
Morgan Michalowski, CNM, WHNP-BC, IBCLC, RN, who works at a large urban, educational and research medical facility in Chicago, Illinois took time to answer our questions regarding the state of L&D.
What are hospitals currently doing (or should do) to keep their maternity/L&D patients safe right now?
Hospital-wide we have a visitor restriction in place, but in L&D we allow one support person to be with the mother. We are universally testing anyone admitted to the hospital for COVID and, in L&D specifically, utilize rapid point-of-care testing. It takes just a few minutes to determine if she is COVID positive.
Hospital workers in L&D wear N95s with a surgical mask over it when in contact with any patient, even if they are not COVID positive.
How are things different in the midst of COVID-19? Is someone still allowed to bewith the mother during labor/delivery?
The first two months, March and April, were a whirlwind. From creating new policies to providing high-quality care to figuring out how to promote bonding when NICU restrictions limit parental access, it was a steep learning curve for all.
We do allow one support person with a mother during labor, delivery, and postpartum. That visitor has to stay at the hospital with the mother through discharge. This seems to be working fine for the moment. We have had patients express interest in leaving the hospital as soon as possible, so they can be home with the rest of their family. Our team has been accommodating those requests. One of the biggest hurdles was figuring out how to support mothers if they’re separated from their baby due to a NICU admission. Most NICUs don’t allow any visitors, which is really tough on a lot of families. We coordinate video calls and check-ins so they feel connected to their baby, but it’s not the same.
What changes have occurred during COVID-19 that you think should be permanent either for the near future or forever?
One strategy in responding to COVID has been to expand the scope of practice for Nurse Practitioners and Midwives, which is having a positive and meaningful impact on care. I hope more states allow for this and continue this practice post-COVID.
Universal testing for COVID will become standard of care, in the same way that TB tests are required prior to starting school or a new job.
What’s happening with the newborns to keep them safe?
Healthy term newborns born to mothers without COVID room in with their mother until discharge. If mom and baby are low-risk, we try and discharge them within 24 hours. During that time, mom and her support person are required to wear masks.
If a mom is COVID positive, her baby goes to NICU until discharge.
Is everyone involved—mother, guest, child—getting tested?
We are currently only testing the mother, no one else. If mom is COVID positive, the NICU handles the care and testing of the baby.
Have the guidelines changed for when Mom and child are released?
No. While we try and discharge clients as quickly as possible, making sure they’re safe with adequate follow-up care is of the utmost importance. If a mom and baby are low-risk with a vaginal delivery, we discharge around 24 hours. If she’s low-risk, but had a c-section, discharge is around 72 hours.
Regarding post-natal care: are moms/newborns getting home nurse visits if
necessary? Is any other treatment happening or have some things moved to
Most postpartum visits can be handled through telehealth. We do see them in person for the six-week postpartum visit. We do not send anyone to the house.
Is there any other information that is important for our readers to know?
I think it’s important for readers to know that hospital workers are doing their very best to keep you, your loved ones, and themselves safe. Some of the restrictions—and the implication those restrictions have on the laboring mother—might not make sense or feel supportive. Every woman deserves to give birth with support and care in a safe environment. We are doing our best to make sure she gets all three.
average American child’s diet improved considerably from 1999 to
2016, with less soda and more fruits and vegetables, though unhealthy
diets remained the rule rather than the exception, researchers
of National Health and Nutrition Examination Survey (NHANES) data on
more than 30,000 young people over the 18-year span indicated that
the proportion with poor diets declined from 76.8% to 56.1%
according to Junxiu Liu, PhD, of Tufts University in Boston, and
shown in their study online in JAMA,
the proportion of youth with an intermediate dietary score increased
significantly during that time period, from 23.2% to 43.7% (P<0.001).
The percentage of young people with an ideal dietary score, however,
remained low, increasing from just 0.07% to 0.25% (P=0.03),
Liu’s team said.
of sugar-sweetened beverages decreased from a mean of two servings a
day to just one (difference -1.0, 95% CI -1.2 to -0.78), and added
sugar consumption decreased from 106 g to 71.4 g a day (difference
-34.4, 95% CI -40.8 to -28.1; P<0.001
consumption of whole grains significantly increased from 0.46 to 0.95
servings per day (difference +0.50, 95% CI 0.40-0.59), and
consumption of total fruits and vegetables increased from 1.62 to
1.81 daily servings (difference +0.19, 95% CI 0.06-0.32; P<0.001
for both), the study found.
1999 to 2016, overall dietary quality improved among U.S. youth,
associated with increased consumption of fruits and vegetables
(especially whole fruits) and whole grains, with additional increases
in total dairy, total protein foods, seafood, and plant proteins, and
decreased consumption of sugar-sweetened beverages and added sugar,”
Liu and colleagues wrote.
diets did not improve in one important area, however: sodium
consumption increased from a mean of 3,166 mg to 3,326 mg per day
far exceeding the 2019 National Academies of Sciences, Engineering,
and Medicine dietary reference intake of 2,300 mg per day.
increase “may relate to steadily increasing consumption of
processed foods and food prepared away from home,” the
researchers speculated. “These findings support the need for
reactivating the currently suspended long-term U.S. Food and Drug
Administration voluntary sodium targets and timelines for reducing
sodium in packaged foods and restaurant foods.”
Asked for her perspective, Lauri Wright, PhD, of the University of North Florida in Jacksonville, who was not involved with the study, said: “I believe this study is good news, showing improvements in youth’s dietary patterns. There might be many things at play here. One might be the impact of the changes in the school lunch program in 2012 (with many changes occurring prior). The reformed school lunches were much higher in fruit and vegetables, lean dairy, nuts, and whole grains, while lower in fat and sodium.”
addition, she told MedPage
email, there has been more education directed at kids and parents
about eating healthier. For example, she said, programs such as Let’s
improved the amount of positive nutrition messaging.
I feel there are many more ‘healthy’ products out there for kids and
parents to choose from,” Wright said. “Water and low-fat
dairy have become the norm over the once popular sugar-sweetened
beverages. Though the study shows we still have a ways to go in
improving youth’s eating patterns, it does show the impact policy and
education can have.”
the study, Liu and colleagues analyzed data across nine NHANES
cycles, from 1999-2000 through 2015-2016. The study included young
people ages 2 to 19 who had completed at least one valid 24-hour
dietary recall. A total of 31,420 youth were included. Their mean age
was 10.6, and 49% were female. Respondents reported all food and
beverages consumed during the past 24 hours, midnight to midnight.
For younger children, proxy-assisted interviews were conducted.
quality was determined by the 50-point American Heart Association
(AHA) 2020 continuous diet score. Poor diet was defined as a score of
less than 20, an intermediate diet was 20 to 39.9, and an ideal diet
was 40 or higher. The researchers also assessed youth diets with the
Eating Index 2015,
and the results were similar.
study findings included the following:
fruit intake increased from 0.46 to 0.68 daily servings, while 100%
fruit juice intake decreased from 0.63 to 0.46 servings (P<0.001
red meat consumption decreased from 0.35 to 0.31 daily servings
while processed meat consumption remained stable
consumption decreased from 55.4% to 51.9% of total energy intake
fat intake increased from 33.2% to 34.5% of energy, and dietary
cholesterol increased from 218 to 254 mg per day (P<0.001
intake increased from a mean of 12.4 mg to 15.6 mg per day (P<0.001)
diets tended to worsen as children got older, reflecting the greater
amount of unhealthy choices available to older children. as well as
the increased freedom to choose them, Liu and colleagues said. For
example, in 2016 the estimated proportion of children ages 2-5 having
a poor diet was 39.8%. That percentage rose to 52.5% for children
ages 6-11 and to 66.6% for those ages 12-19.
of the study, the researchers said, included the inaccuracies
associated with self-reported dietary recall, as well as the
cross-sectional nature of the analysis, which did not allow for
evaluating dietary changes among individuals, only of national
study was supported by the National Institutes of Health and the
American Heart Association.
reported no conflicts of interest; co-authors disclosed relationships
with the National Dairy Council, PepsiCo, General Mills, and other
companies and organizations.
COVID-19 social isolation measures are designed to make the population safer, but the stresses of isolation can exacerbate the risk of child abuse. How can this pandemic period affect at-risk children, and what can we do about it? DailyNurse asked Dr. Normajean Colby, RN, PhD, CNE, CPN, Coordinator of Pediatric Nursing at Widener University’s School of Nursing, about the concerns of child abuse experts in what she describes as a time of “unprecedented changes… with tens of millions of our nation’s children at home instead of in schools or daycares.”
Why children at risk of abuse are in particular jeopardy now
Dr. Colby: The number of factors that contribute to the risk for
child maltreatment may have potentially increased for families in our
nation. Even where those factors themselves haven’t changed, what
has changed is that parents and children are now isolated together
24/7 and for an undetermined length of time.
Another vital reason that this unprecedented time in our history makes this period a particularly dangerous time for children at risk of abuse is that the eyes that are generally on these children as a safety valve are not present. What I mean by this, is that teachers, daycare workers, Sunday School teachers, coaches, etc., are not seeing these children on a regular basis. When business is as usual, these are individuals in a child’s daily life that can recognize if abuse may be occurring. In fact, during this time, it is expected that the number of child abuse reports will decrease temporarily, but that in no way means that the actual incidence has decreased.
How can we reduce the dangers of child abuse at this time?
Dr. Colby: We need to truly “come together” as has been the
mantra in our nation lately. It is our responsibility to help each
other to successfully get through this period of time. What we can
certainly do is to check on our neighbors and friends, give a phone
call, drop off a note, and connect with others, while maintaining
pediatric healthcare providers, pediatrician offices, daycares, early
intervention programs, etc. we can reach out to the caregivers,
particularly those who may have more of the risk factors that can
contribute to the risk for abuse. Reach out and check in, see how
they are doing, how the kids are doing, and offer an empathetic ear
and ideas for the kids. These folks know the families and have a
relationship often with the families, so reach out!
Also, nurses and healthcare providers are mandated reporters, therefore it is federal law that they report suspected child abuse. The reporter does not have to “prove” such abuse; that task is up to the Child Welfare Agency. But any suspicion of child abuse must be reported. [To make such a report, contact your state child abuse protection agency or call the Childhelp National Child Abuse Hotline at 1-800-422-4453 ]
Dr. Colby: tips for all parents and caregivers to reduce family stresses
Give yourself a break! Keep expectations of yourself as a caregiver and of your child/ren realistic and in check. [many times abusive caregivers have higher expectations for a child, that may even be above their capacity developmentally, and when the child does not live up to that expectation, the caregiver becomes frustrated and that is when physical abuse may be more likely to occur]. It’s OK if there are dishes in the sink, or laundry in the basket. There are really worse scenarios.
When you feel yourself getting frustrated, take a slow deep breath, hold a few seconds, and slowly exhale, then slowly count from ten to one backwards, before you respond or react.
Look for silver linings. Maybe even make it a family activity, before bed or during a meal, ask “What is a good thing about today?” Even if it is a small or silly good thing.
Never ever shake a baby! If the baby is clean, and fed, and seems all right, place the baby in its crib and step away, put on the TV or put headphones on and listen to music, being sure to check on the baby periodically, but never ever shake a baby!
Practice self-care. Get enough sleep, eat healthy if possible, get exercise or incorporate movement into every day, go outside, yoga, meditation, prayer, relaxation techniques, stay connected to others whether email, text, phone, skype/zoom. Turn off the news – you don’t need to be exposed all day long to the news.
Know that you are not alone – Frustration with stress is normal. Childrearing is rewarding, but also can be tiring. If you can connect in some way with other parents/caregivers to share ideas and empathize, across back yards, via phone or technology. Talk to someone you know. Reach out to a healthcare provider or clergy member.
Always remember: children pick up on the anxiety of those adults around them!
“I think caregivers can be disappointed at times,” said Vicki Williford, a
chronic care nurse in Greensboro, North Carolina. “The home health nurse comes
and goes, and [the caregiver] still has another 23 hours to go.”
That’s 23 more hours to make sure the care recipient has taken medication,
avoided falls, eaten healthy meals, and made it to the bathroom in time — all
of which have to be supervised remotely by long-distance caregivers.
All caregivers, regardless of
geographic proximity, are met with tasks that challenge emotions and
resilience, as they work to provide the best possible quality of life for a
loved one in need of support. They may have difficulty accessing clinical
training, balancing caregiving with a full-time job and personal life, and
managing the length and scope of caregiving.
Those supporting a family member
from a distance may experience added stress from coordinating logistics
remotely, without the affirmations of face-to-face interactions from a health
care team and their loved one.
Challenges unique to long-distance
Traveling to and from the care recipient’s home
Using technology to stay in touch
Limited in-person communication with the care recipient
Building provider relationships from afar
Coordinating legal and financial concerns remotely
Planning visits for other family members
Keeping all parties up-to-date
Wavering confidence about choices made for the care recipient
Digital Tools for Long-Distance Caregivers
Some caregivers may find help through digital tools that
make it easier to check in on a care recipient, which can include:
Mobile Apps – For face-to-face communication
Smart Devices — to adjust home temperature or door locks
Wearable Devices — to transmit vitals or call 911 in case of an emergency
Home Cameras — to monitor activity and visitors; for keeping track of medication schedules and deliveries; providing alerts of home break-ins
Keep in mind, not all technology seems user-friendly at first, so it’s important to check in with all parties — including a health care provider — about the level of comfort using new tools.
Being Part of the Health Care Team
Many care recipients have a team of providers, such as nurses, managing
multiple aspects of their treatment. Caregivers can certainly be a part of that
team, even from a distance. That team can also offer support for the caregiver.
“We don’t take over people’s lives,” he said of caregivers. “We work with them to provide support to enhance their lives to be more functional and help them live more the way they want to live.” Both the caregiver and provider need to understand the strains that each party is experiencing, which comes from clear and consistent communication. There are several ways family members can demonstrate to providers they want to be an active participant in a loved one’s care.
Building a Relationship with a Provider Remotely
Identify a member of the family who has the capacity and availability to be granted power of attorney for medical decision-making and communication with the primary provider.
Establish the need for regular check-ins and preferred modes of communication.
Attend appointments when possible. If it’s not possible to be there in-person, try dialing in, or follow up with a phone call to the provider and care recipient.
Keep notes of changes in health or questions about the care recipient’s needs.
Make a list of medications and other treatments in order to support medication adherence and monitor changes in therapies.
Understand that a treatment plan will evolve as the care recipient’s condition changes, and be open to that change.
Williford said it’s common for
families to lack consensus on a treatment plan for a patient with an unexpected
hospitalization, which can make a provider’s job much more difficult.
“Families come in from all these
different states, out of town, and then they’re now faced with: ‘What do we do
with Mom?’” she said. “They’re trying to decide, and yet the mom’s saying to
me, ‘No one asked me what I wanted.’”
Having these conversations as a group can help the care recipient feel that they have agency over their treatment plan and keep everyone on the same page — regardless of what time zone they’re in.
A Taste of One’s Own Medicine
Supporting a loved one from afar involves complicated responsibilities and
constant communication that can prove taxing. It’s common for long-distance
caregivers — especially those with less support — to feel emotionally burned out or exhausted. Being far away from
the care recipient can increase anxiety about a loved one’s wellbeing, and may
be compounded by stress of periodic traveling or lack of sleep for providing
care across different time zones.
Without proper self-care, caregivers may experience caregiver strain, or a feeling of burnout that leaves
individuals unable to perform daily tasks or cope with feelings of anxiety.
“You know you’re experiencing burnout as a caregiver if you’re waking up in the morning with a sense of dread,” said Jacobs.
How to Manage Burnout as a Long-Distance Caregiver
Set a cadence for phone calls.
Make time to self-reflect each day.
Take an inventory of your emotions.
Accept help when it’s offered; ask for help when it’s not.
Utilize a care team on the ground to perform in-person tasks.
Take notes during visits so there’s less to memorize.
Drawing boundaries is one thing;
adhering to them is another. Caregivers have to carve out time to care for
themselves and get the help they need as well. Jacobs said he uses a marathon
as a metaphor for caregiving.
People “need to see this as a long, arduous course for which they need to really take care of themselves along the way,” he said.
“They run past a water station at
mile five and people are waving water bottles at them,” Jacobs said. “That kind
of self-replenishment on a regular basis develops some sort of emotional
Even when distance is not a factor, caregivers are still at high risk of being overwhelmed. In fact, boundaries can be extremely difficult for spousal caregivers in particular, who feel a heightened sense of obligation for their loved one’s well-being. Spousal caregivers are at increased risk for burnout. Many of them — almost one in five — are outlived by their husband or wife, according to a 2018 study published in the journal Alzheimer’s & Dementia. Accepting an offer of assistance, even when it doesn’t seem crucial at the time, can help caretakers sustain the energy and will needed to provide the best quality care, while still finding time to rest and enjoy life with their loved ones.
Resources for Long-Distance Caregivers
Refer to the organizations below for
further reading and resources on how to provide high-quality care for a loved
one, from afar.
The MammaCare Foundation recently issued a statement saying that according to recent studies, most breast cancers are found by hand. Mark Kane Goldstein, PhD, a MammaCare Foundation senior scientist stated, “A palpable lump, detected by hand is the most common symptom of breast cancer. Although mammograms—x-rays of the breast—can be useful, their images are masked by breast density in nearly 50% of women. Physical examination, however, is unaffected by density.”
Goldstein took time to answer questions for us about MammaCare and the foundation’s mission to help train every hand that examines a woman, including her own.
Why was the MammaCare Foundation established?
Our research on early breast cancer detection began at the University of Florida and Malcom Randall VA Medical Center because mortality from late stage breast cancer was an epidemic that continues to this day. We reported in a series of studies supported by the National Cancer Institute that properly trained hands will reliably detect small early, 3mm, pea-sized breast cancers (suspicious palpable tumors) without increasing false positive detections. Our original intention was simply to publish and promulgate the evidence and standards knowing they would enable clinicians and women to detect small early cancers.
We assumed, naively, that the training procedure would be
integrated into practice because it was an easily teachable skill that could
have a meaningful positive impact on women’s morbidity and mortality from
breast cancer without the dangers and expense or radiation. Sadly, resistance
from the imaging and radiological industries, and surprisingly from public and
private women’s health care agencies as well as U.S. Government health agencies
impeded training progress for a number of years as data accumulated.
Currently, breast cancers first detected continue to
remain 5 to 10 times larger and at a later stage than necessary. So, in
response, and with support from scientific agencies, the original research team
formed MammaCare to make the skills and standard for breast exam competency
What is MammaCare’s mission?
MammaCare’s mission is to train every hand that examines a woman for breast cancer. When the team of scientists, physicians, and biomaterial engineers began investigating the capability of fingers to detect breast cancers at the University of Florida, we were surprised that there were no prior evidence-based standards — no published research on the subject existed. We also learned that most women received clinical exams that were random or deficient, incapable of palpating small, suspicious tumors. We were puzzled by opinion and conclusions in the medical literature that the tactile sense was limited to feeling large, late-stage lesions. The only clinical papers published at the time reported that breast cancers discovered by hand and were late stage, large, 3-3.5 centimeters (about the size of a ping pong ball).
Our data from experiments found that with a brief training session using tactually accurate breast models, all hands were able to reliably detect 3-millimeter tumors, 10 times smaller than reported without increasing false positive detections. It was clear that breast cancer detection would be the province of the growing imaging, radiological industry. So, we created MammaCare to assure that a standard for a universal, safe, cost-effective standard of physical examination of the breast would be available.
Fingers feel and read sub-millimeter Braille dots
with absolute accuracy.
Many of the reports and studies on MammaCare are here.
Most women—and probably most nurses, female or male—believe thatmammograms are the best way to find lumps. What does the MammaCare wayoffer that regular self-breast exams don’t?
Mammograms and increasing use of radiological imaging are widely available and most often used. It is puzzling, however, to note the evidence that indicates these technologies are not the most likely way breast cancer is first found. Moreover, numerous landmark studies by colleagues such as Joanne Elmore point out in a series of studies that mammography is only as good as the training and experience of the radiologist who reads them with his eyes. The same is true of untrained and trained hands with an important exception — the exam is free of ionizing radiation — an increasing concern — and mammograms often miss palpable tumors. Finally, between 40 and 50% of all women have dense breast tissue that clouds mammograms making interpretation difficult or impossible.
MammaCare training is now being installed in colleges of nursing and medicine providing breast exam skills and standards of practice for thousands of student nurses and physicians across the U.S. and elsewhere as indicated on the student login page.
What should nurses know about MammaCare?
That MammaCare has online and live training and certification programs, recognized continuing education courses and credits, and that new certification courses are conducted via live teletraining at the clinicians’ facility. There is a map on the front page of mammacare.org that should provide access to MammaCare certified nurses and their organizations.
Many of the colleges of nursing (and medicine) in the competency network are employing a new breast exam simulator that teaches and measures exam performance (the MammaCare Simulator Trainer) that was funded in part by the National Science Foundation.
In addition to improved detection of suspicious breast tumors, the MammaCare training protocol reduces false positive detections on clinical screening exams that are performed on well women screening.
Perinatal depression is the occurrence of a major or minor
depressive episode during pregnancy or up to one year after childbirth, and
affects as many as one in seven mothers. This term also includes postpartum
depression (PPD), a common complication that occurs after childbirth. But routine screenings for these occurrences is
not standard for most health care providers.
Recently, the U.S. Preventive Services Task Force published
a recommendation to provide or refer pregnant women with an increased risk of
perinatal depression to interventions. But while this report has just been released,
Dr. Clevesy has been working to progress research and care for those with PPD,
especially early on in pregnancy.
Dr. Clevesy’s work has major positive impact both locally
and nationally, especially as discussions of mental health overall are becoming
more common and more open throughout the United States. As more people open up
about their mental health in media and online, women are feeling more
comfortable and secure discussing their own concerns and issues with their
healthcare providers, allowing Clevesy and her colleagues to help strengthen
their work in the Las Vegas area.
Dr. Clevesy also shared that since implementing the new
system, PPD screening documentation rates have nearly doubled. Dr. Clevesy’s
work is crucial for enlisting more Las Vegas health care providers to provide depression
screenings for their pregnant patients, whether they use her screening tool or not.