 Good morning and happy International Day of the Midwife. This is a presentation called Preparing for Publication, Student Perspectives, and the wonderful students of Georgetown University's Nurse Midwifery and Women's Health Nurse Practitioner programs are going to share some of their learning with you. And here today is Nancy Jo Reedy, their instructor as well as Esther Bowers, Ellsworth Bowers. And they're both going to introduce the students back to you, Nancy. Welcome to you all over the world. Please join us for this. Welcome to all of you all over the world. We'll give you the course course. First-hand courses. Turn on your mic, please, Nancy. Can you hear me? So that's just. Lorraine, can you hear us OK? Lorraine. I can hear Cindy, but I couldn't hear Nancy. We've got the technical solved. Here's Nancy. I'm so sorry. Where's the microphone? It's right in here. OK, that'll work. Welcome to everyone all over the world. My name is Nancy Jo Reedy. I'm the course coordinator for the course in our program that focuses on women with complex problems and pregnancy. Graduate Midwifery students write papers, but those papers stay in computers and on shelves. We wanted to take all that work and knowledge they put into their papers and enabled it to be shared with the entire Midwifery community and women's health providers. For this reason, the term paper was converted to an article for publication. The student chooses a topic of interest and the journal that is appropriate for the article. Study and publication are the routes we use in professional communication. And our students will be ready to be active participants in learning and disseminating new information. Esther will share a bit about the support we provide for the student in the process. Hello, my name is Esther Ellsworth Bowers, and I'm an instructor in Georgetown University's Midwifery and Women's Health Program. I'd like to briefly discuss the ways that we work to support students while writing their articles for publication. First, we coach students selection of paper topics. We encourage students to define not only a broad topic of interest, but a specific population or subtopic they want to research. For example, if a student is interested in diabetes and pregnancy, she might focus her paper toward gestational diabetes in women over age 35. Second, we review student outlines several weeks prior to paper submission. This helps students address all author guidelines for their chosen journal, as well as all the elements of the Midwifery management process for their chosen topic. Third, as instructors, we provide feedback on final papers that can guide further revision rather than simply grading those papers. And fourth, we're available after the end of the course for students who want to assist or, excuse me, have assistance in preparing their articles for submission. The first student who will present for us is Lindsay Ackerson. Hi, my name is Lindsay Ackerson. I reside in Kansas City, Missouri, which is a town position smack dab in the middle of the United States. Both Kansas and Missouri are a little slow on the uptake regarding Midwifery. We do not live in a full practice state, and there are only a small handful of midwives in the area. I spent my last two semesters at a women's health care clinic attached to a large hospital in the heart of Kansas City. My preceptor is a family nurse practitioner with over 30 years of experience, primarily in obstetrics and gynecology. There are three nurse practitioners in the office, several residents that vary depending on the week and three staff physicians, one of which is always on site to answer questions or oversee care. The hospital itself is the busiest in the area with a level three NICU and houses one of the nation's only maternal cardiac care programs, specializing in care of women with congenital or acquired cardiovascular disease. It is a teaching hospital and clinic, which obviously benefited me greatly in my current role as a CNM, WHNP student. There were very few questions my preceptor couldn't answer with a, well, ACOG advises that we do this or the protocol for caring for the patient entails this until we met a patient with suspected intrapathic cholestasis of pregnancy. I obviously knew I had to research this topic further and report back to my preceptor everything that I could dig up. My intentions for publication were with the Journal of Midwifery and Women's Health, which required a case study to begin my publication. This was ideal because I had just encountered this very patient. ICP of pregnancy is a pregnancy specific disorder of the liver identified by maternal parietus in the second half of gestation. Alter liver function and elevated serum bile acids. Although a diagnosis of ICP is extremely rare, subsequent sequela can prove disastrous for neonatal outcomes if not promptly identified and managed appropriately. The pathophysiology of ICP is poorly understood, but may include genetic, endocrine and environmental contributing factors. ICP involves an accumulation of bile acids in the liver with subsequent deposition in the skin, bile salt deposition in the skin and a seed severe parietus, namely on the soles of the feet and the palms of the hands. Parietus is often so intense that psychological distress ensues. Occasionally, the parietus is accompanied by anorexia, nausea or vomiting, further impairing maternal quality of life. Feldom, jaundice and fat malabsorption with subsequent steataria occur, causing vitamin K deficiency. Diagnosis of ICP is dependent upon patient report of symptoms and laboratory values, namely bile acid levels that exceed 10 millimoles a liter. The incidence of ICP averages about two for 10,000 pregnant women in the United States. Colostasis recurs in approximately two-thirds of subsequent pregnancies. Vitamin K deficiency that results from mild steataria associated with the colostasis itself or the colostiramine therapy for the colostasis increases the risk of postpartum hemorrhage. Less critical maternal complications include impaired quality of life. Maternal complications pale in comparison to potential neonatal risks. ICP significantly increases incidence of four fetal outcomes, such as meconium ileus, premature delivery, fetal distress, or even stillbirth. Bile salt values that exceed 40 millimoles correlates with increased preterm birth, non-reassuring fetal heart tracing patterns in labor and subsequent intrauterine fetal demise. Treatment and management of ICP is influenced by gestational age, fetal status and presence of meconium stain amniotic fluid and the severity of maternal diseases evidenced by maternal symptoms and serum bile acid levels. Urso deoxycholic acid or ursodyl is the most common recommended therapy for ICP. It is a hydrophilic bile acid stimulating bile acid excretion, thereby normalizing the serum bile acid profile and decreasing maternal puritis. Management of ICP often consists of early induction of labor in an attempt to prevent fetal death. Complete maternal symptom resolution typically occurs within three weeks of delivery. When patients less than 36 gestational weeks are diagnosed with ICP and are discovered to have serum bile acid levels that exceed 40 millimoles, treatment strategy to avoid fetal demise includes inpatient management with continuous electronic fetal monitoring, urso diotherapy and serum and serial serum bile acid levels and liver function tests. Delivery is offered at 36 gestational weeks after fetal long maturity is confirmed with amniocentesis or delivery is accomplished at 37 weeks without amniocentesis confirming long maturity. Abnormal fetal heart rate tracings or other obstetrical comorbidities influence delivery time as well. For the patients with serum bile acid levels between 10 and 40 millimoles, semi-weekly fetal non-stress testing and urso deoxycolic acid therapy are warranted until delivery at 36 weeks with confirmatory amniocentesis. If an amniocentesis shows evidence of meconium-stain fluid, delivery is warranted at that time. The most recent treatment recommendations have been shown to drastically reduce if not completely mitigate fetal death secondary to intrahepatic cholestasis of pregnancy. Thereby, warranting further research and the development of patient care protocols by women's health governing bodies. Thank you so much and happy International Day of the Midwife. Hi, everyone. My name is Elizabeth Solis and I currently live in the Chicagoland area. This past semester, I worked at two clinic sites that varied in patient population. One clinic site served women desiring homebirds and were of low risk. The second site managed women of higher risk and had a hospital birth. The publication topic I worked on was identification and management of fetal growth restriction. I chose this topic because I found in my clinic experience women measuring smaller than their dates was a common finding and the various midwives I worked with managed it differently. This sparked an interest in me as I wanted to know what the evidence had to say about fetal growth restriction management. As I began to do my research on maternal and infant mortality in my state of Illinois, I found that one of the top three leading causes of infant deaths was low birth weight and prematurity. It occurs in about 10% of pregnancies and is associated with preterm birth. It is important to identify fetal growth restriction early and distinguish it from small for gestational age by identifying maternal risk factors through accurate and thorough medical history taking, genetic screening and physical examination. Through surveillance at every prenatal visit, midwives can manage appropriately and collaborate with other healthcare providers when needed to improve outcomes for both mother and baby. ACOG defines fetal growth restriction as the estimated fetal weight less than the 10th percentile for gestational age. Current evidence shows that fundal height measurements is a cost effective screening tool to appropriately evaluate fetal growth but should be used with good clinical judgment. If there is a three centimeter or greater between gestational age and fundal height measurement, additional screening is indicated through ultrasound as it is the gold standard for diagnosis of fetal growth restriction. Once fetal growth restriction is diagnosed, collaboration with maternal fetal medicine and patient education is necessary to improve birth outcomes. Future research is indicated to improve current guidelines as there is no universal diagnostic criteria. Though ultrasound is the gold standard for fetal growth restriction diagnosis, there is always room for improvement of methods to assess fetal biometry in research and in practice. The journal I chose is the Journal of Midwifery and Women's Health. I chose this publication as I find the literature they publish helpful in increasing knowledge and evaluating new evidence for care. My intent for future writing and publication is to help me midwives have a go-to resource when they are unsure of protocol and management. Thank you and happy International Day of Midwives. Hi, my name is Andrea Geekis and I live in a small rural area of Northern California about an hour north of Sacramento called Grass Valley. My clinic site is the only MediCal or Medicaid clinic available for at least 45 miles and has only the only CNM in the area. Unfortunately, she no longer does deliveries at home or in the hospital and only works in the clinic. We do have seven to 10 active licensed midwives for home birth options available. I chose opioid use disorder or OUD management and pregnancy, specifically methadone versus buprenorphine management because my area is inundated with opioid addiction affecting easily a quarter of my pregnant population. We have a wonderful substance abuse inpatient and outpatient program called COR, but we do not have any prenatal providers involved in the program other than when they come for prenatal visits. I hope to change this and become the connection between the prenatal providers and substance abuse providers from my home. Opioid addiction is a hot topic in national news with OUD on the significant rise in pregnant women. With the high street cost of narcotics, many women turn to heroin a cheaper and easier high. National opioid overdose rates have increased by 400% between 2000 and 2014 with heroin use and overdose up by 500%. Neonatal abstinence syndrome has increased sixfold accounting for $1.5 billion in hospital charges due to increased NICU stays and treatments. Opioid use alone has a 74-fold increased risk of SIDS for newborns and untreated or under-treated pregnant women. As midwives and our foundation of meeting women where they are at, we are profoundly suited to care for this population in an incredibly vulnerable and stressful time. We do not just treat patients, but we care for women and develop relationships built on trust, acceptance and openness. Medication management with methadone or buprenorphine in pregnancy decreases the chance of relapse preterm birth, lower birth weight infants and risky life-threatening behaviors. Methadone has been the gold standard of treatment since the 1960s, but requires daily visits to the methadone clinic or a substance abuse program. Buprenorphine allows women increased autonomy by taking their medication at home and following a closer to normal prenatal schedule. Both therapies have shown great outcomes for mothers and infants, though both have the risk of neonatal abstinence syndrome. Some studies report decreased lengths of neonatal abstinence symptoms, decreased need for medication and neonates and decreased hospital stays in the neonates. But with buprenorphine treated mothers leading to the assumption that buprenorphine is better than methadone management options. It is important to note the treatment needs to be personalized to the patient's aid, not just the neonatal outcome. Women with long history of opioid use, those that have a history of polysubstance abuse, including benzodiazepines, may fare better on regular supervised visits with methadone. This allows them daily check-in with substance abuse providers in support. Women who have increased social support show initial self-efficacy and autonomy and who are capable of self-managing their symptoms will be better candidates for buprenorphine. Women who are stable on their medication-assisted therapy prior to pregnancy should remain on that therapy to prevent withdrawal. Women should not be switched from methadone to buprenorphine unless they choose it due to increased risk of withdrawal and relapse. But women who feel buprenorphine is not covering their symptoms can be moved to methadone with the understanding that their medication visits would increase. Since both therapies have shown similar results for pregnant women, more researchers needed to determine if one therapy is clearly better than the other in reducing neonatal abstinence syndrome. The neonatal providers do not prescribe methadone, but we as midwives and MPs can be trained to become prescribers of buprenorphine. More of us need to step up and become comfortable with managing and treating pregnant women with OUD. I chose the Journal of Midwifery and Women's Health for Publication to increase awareness of opioid use disorder and management within the midwifery population and to hopefully inspire more midwives to take action and caring for OUD pregnant women. I hope to publish my paper and become an active participant on the treatment of pregnant women with opioid use disorder in my community. Happy day of the midwife. My name is Melissa Horton and I live in Fredericksburg, Virginia, just south of Washington, D.C. I've been a labor nurse for 10 years and am currently enrolled in the Georgetown Midwifery Women's Health Nurse Practitioner Program. I'm in a clinical site in Richmond, Virginia and the practice works of a variety of women from different cultures and is a 24-7 midwifery service. My paper for publication is titled, The Challenging Management of Intra-Hepatic Colestasis. I chose this topic because of just that. It is such a challenging disorder to manage. I've had an experience which piqued my interest. I had a patient who had a fetal death at 36 weeks due to this disorder and I felt I wanted to know more. ICP is a disorder of the liver and pregnancy which has a high risk of fetal death and iatrogenic return birth. This disorder affects the bile acid pumps in the liver and is multifactorial. It has many genetic components leading to the recurrence of many women up to 90% and has familial lines, especially in the areas of South America and the incidence in Chile is around 15% of women that might be affected. There's evidence suggesting that a high estrogenic state causes bile acid pumps to malfunction. This in turn causes a buildup of bile acids decreasing the production of bile and as the bile acids and bilirubin continue to conjugate, they filter into the bloodstream and affect the mother's skin causing puritis and then buildup in the fetal compartment. This buildup in the fetal compartment causes stress on the infant with high rates of meconium stain fluid and fetal death after 37 weeks of gestation. This disorder is primarily a third trimester disease, however, can present as early as eight weeks. The presentation is generally puritis without a rash except for excretion from scratching and this generally happens at nighttime on the soles of the feet and the palms of the hand. Nausea, vomiting, anorexia, fatigue and epigastric discomfort can also be presenting signs of ICP. Burstening, puritis, deodoria, dark urine and jaundice can be clinical signs of progression and decrease in liver function. As midwives, it is important to recognize the symptoms and run bile acids and liver function lab work as it may take time for the bile acid results to come back. It is appropriate to start treatment of highly suspicious for ICP. This is because ICP can be a fast progressing disease in significant fetal implications. There is no cure for ICP. However, there are management strategies and medications which can alleviate the maternal discomforts. UDCA has long been used to alleviate maternal itching. There is new evidence finding that ADCA or ursodial is also improving fetal outcomes by decreasing bile acid amounts. According to the literature, delivery at 37 weeks is recommended based on the increased risk of fetal death after 37 weeks. An alternative is delivery if bile acids are greater than 40 millimoles per liter. Increased surveillance, fetal surveillance may provide some comfort to the provider and the patient that cannot be considered significant reassurance as fetal death can happen quickly without warning even after reassuring fetal testing. As an important side note, with a decrease in bile production, malabsorption of vitamin K can be an issue. If the woman has any signs of steateria, consider giving vitamin K at delivery to prevent postpartum hemorrhage. Between six and eight weeks postpartum, it is recommended to do follow-up lab work to ensure no ongoing hepatic impairment. In the future, more research is needed in understanding delivery management strategies, understanding genetic components which could help with early treatment and the use of dandelion root and milk thistle as an option for ICP treatment. I chose using clinical rounds in the Journal of Midwifery and Women's Health. This is an excellent resource for evidence-based practice in midwifery. It presents real-life situations with appropriate management strategies. I'm currently not sure what the intent for my paper for publication is yet. I definitely need to tweak parts and possibly find more supporting evidence and management. I've always been challenged with writing. I thoroughly enjoyed this challenge to expand my research ability and synthesis of research. I look forward to continuing my education and writing abilities. Thank you for your time and attention and happy International Day of the Midwife. Hi, my name is Tiffany Gollum and I'm a midwife student at Georgetown University. I'm from Huntsville, Alabama and we unfortunately have no midwives in my area. There's great need for more midwife care in the state of Alabama with less than 20 practicing nurse midwives in the state currently. I have temporarily moved to Columbus, Georgia for my midwife clinical starting this month but hope to return back to Alabama following. This clinical site is a women's health office with seven physicians and three midwives. The midwives have their own set of patients separate from the physicians and to attend births at two hospitals in the area for unmedicated and medicated births. I chose the topic of short cervix for my paper because I have a close friend who required a circlodge with her third pregnancy for a short cervix and I was interested in understanding the proper management of her condition. It is also important due to the significant risk it is for preterm birth if left untreated. With prematurity being the leading cause of infant deaths in the U.S., it is important to determine preventable causes and consider appropriate treatment. My article begins with a case of my friend who had a full term 39 week delivery with her first baby followed by a 30 week delivery of twins and was found to have a short cervix with her third pregnancy which was a singleton pregnancy at 22 weeks gestation. In researching the proper management, a circlodge is indicated for those with a short cervix of less than 25 millimeters prior to 24 weeks who've had a prior preterm birth. For patients who have not had a prior preterm birth for gesturing is the treatment of choice for prevention of preterm labor. The placement of a circlodge has not been shown to reduce the incidence of a preterm birth and those who have not had a history of a preterm birth. For the case presented in this article, her preterm birth was complicated by a twin gestation and that raises the question of the best treatment plan for a subsequent short cervix. That scenario was not discussed well in the literature regarding the cause for the preterm birth and as an area for future research need. Some additional controversy is the question of whether universal screening for cervical length by transvaginal ultrasound is indicated at mid pregnancy. Standard mid pregnancy ultrasounds are done to assess fetal anatomy and are done trans abdominally. A cervical length obtained during that exam is typically overestimated and very significantly by the mother's anatomy. Currently ACOG does not recommend that but some studies have been done to show that it may be beneficial. Future research should be done to determine the cost benefit on reduction of preterm births by identifying those with a short cervix and treating appropriately. I chose the journal of midwifery and women's health to write for because of the format of the clinical rounds article type. I believe it fit my topic in case presentation appropriately. I hope to be able to submit this article for publication and to write more articles in the future as I gain experience in my career. Thank you for your time and happy International Day at a Midwife. Hi, my name is Brittany Ross and I am honored to have this opportunity to present my manuscript to you today at the annual virtual International Day at a Midwife. I recently completed my antipartum clinical rotations at a small community hospital and will begin my interpartum and integration clinical rotation at larger hospitals serving women of various racial and ethnic backgrounds. After graduation, I hope to practice as a certified nurse midwife in Boston, Massachusetts while focusing on my passion of obstetrics care and preventative healthcare for women of all ages. The objective of my manuscript was to provide clinicians with an evidence-based review of the safe and effective management of a post-term pregnancy. I was drawn to this topic to seek clarification of common challenges providers may face, including the implementation of expectant management versus induction of labor for a pregnancy approaching 41 to 42 weeks gestation. A post-term pregnancy extending to 42 weeks gestations or beyond may present significant risks to both the mom and her baby. Considering these risks with preexisting individual comorbidities will guide clinicians to provide quality care for a post-term pregnancy. Maternal risks may include postpartum hemorrhage, operative vaginal delivery, choreoambionitis, prolonged labor and cesarean birth. Terranatal risks may include meconium aspiration, asphyxia, umbilical cord complications, macrosomia, bone fractures, depressed five-minute apcar scores and increased rate of NICU admissions. A midwife plays a critical role in accurate dating of a pregnancy to prevent unnecessary interventions due to dating error. The use of first trimester crown rump length via ultrasonography has proven to yield more accurate dating than a women's subjective report of her last menstrual period. A study by Sevitz et al. found a 2.8 day longer discrepancy and gestational age with the use of LMP for dating. Another study by Bennett et al. reported a statistically significant reduction in post-term pregnancies and induction of labor with the use of first trimester ultrasound. Although the pathophysiology of a post-term pregnancy is not clearly understood, evidence reveals a complex interaction of hormonal, mechanical and inflammatory processes. A slower rise in placental production of corticotropin-releasing hormone is thought to play a critical role in the delayed onset of labor due to the delayed inhibition of placental progesterone synthesis. Although antinatal surveillance may differ between practice settings, the American College of Obstetricians and Gynecologists recommend use of a non-stress test, contraction stress test, BPP or modified BPP initiated twice weekly at 41 weeks of gestation for a woman opting for expectant management. Additional assessment of amniotic fluid volume or single deepest vertical pocket is also recommended for the detection of oligo-hydramidos often observed in post-term pregnancies. Although the timing for induction of labor remains controversial, the American College of Obstetricians and Gynecologists state that clinicians should recommend induction at 42 weeks and consider induction between 41 and 41.6 weeks gestation. A cockaring systematic review of 22 randomized controlled trials reported a decreased incidence of cesarean birth, meconium aspiration and perinatal death with a policy of induction of labor at 41 weeks versus expectant management. Interventions including membrane sweeping and trans cervical balloon catheters can also be offered to release decidual and cervical prostaglandins and stimulate cervical ripening. Use of the Bishop's score is also recommended to determine cervical readiness and predict successful induction of labor. Counseling on the risks, benefits and effectiveness of complementary and alternative methods including castor oil, coitus, chamomile, evening primrose oil and acupuncture may also play a role in a midwife's care of a post-term pregnancy. Acknowledging the hallmarks of midwifery, a midwife can employ skillful communication, guidance and counseling of risks associated with post-term pregnancy as well as the risks and benefits of various induction methods. Furthermore, a midwife can empower women as partners in their healthcare by presenting them with appropriate treatment options and honoring their preferences in the management of their care. I chose to develop my manuscript for the Nursing for Women's Health Journal because it provides professionals involved in providing nursing care for women with a concise, practical and easy to read format and a topic of interest. My intent for future writing and publication is to expand my manuscript to include a more detailed review of current evidence on complementary and alternative treatments for a post-term pregnancy before submitting my manuscript for publication. Thank you again for this wonderful opportunity I wish you all a happy International Day of the Midwife. Hi, my name is Alexa Valesky and I currently live in Fargo, North Dakota. Midwifery is not very big in North Dakota and as of 2015 there were only 16 midwives practicing in the state. I am doing my clinicals at Family Healthcare in Fargo which is a HRSA clinic. We work primarily with immigrant and underserved populations. We do deliveries at Sanford Health Hospital which is the new state of the art facility that just opened in 2017. I decided to write my paper for publication on H. Pylori in pregnancy. I chose this topic because at my clinical site H. Pylori seems to be very common in pregnancy but most to the point where it seems like it's exacerbated or reactivated in pregnancy. Many women at our clinical site come in complaining of excessive heartburn, nausea, vomiting, tyalism and upper abdominal pain a short time into their pregnancy. Any of these symptoms weren't in H. Pylori test since we serve primarily immigrant populations. Many of these tests come back positive and these women have never had symptoms outside of pregnancy. I wanted to look at the research regarding risk of H. Pylori in pregnancy. I wrote a clinical rounds article for the Journal of Midwifery and Women's Health to focus on these pregnant women with H. Pylori. Approximately half of the world's population is colonized with H. Pylori. The bacterium is often contracted in childhood and will persist until treated. The recurrence rate of H. Pylori is about 13% due to colonization of the oral cavity. Most of transmission include oral-oral, fecal-oral, iatrogenic and vertical transmission. 80% of individuals with H. Pylori outside of pregnancy are asymptomatic. Classic symptoms include dyspepsia, upper abdominal pain and epigastric pain. In pregnancy, hyperemesis or severe nausea and vomiting beyond the length or frequency of typical morning sickness may be one of the hallmark signs of H. Pylori. Midwives need to recognize symptoms and perform diagnostic testing in pregnancy. Serology can be used for initial testing, however it is not useful in determining reinfection if a patient has already been treated because IgG will still be positive. The urea breath test is the most commonly used test for H. Pylori. It will detect any current infection. Stual antigen testing can also be used, but usually is only done when the breath test is not available. For patients on a proton pump inhibitor, the recommendation is to discontinue this medication for two weeks prior to a breath test to decrease false negative results. Patients can be put on an H2 blocker for these two weeks to help with symptoms. And if unable to discontinue the PPI, stool antigen testing should be performed. I just wanna briefly touch on some of the research regarding H. Pylori risk in pregnancy and speak to the importance of recognizing symptoms. One study found that pregnant women with dyspepsia, hyperemesis, and prolonged GI symptoms past the first trimester were very likely to be H. Pylori positive. Another study found that pregnant women were more likely to become infected with H. Pylori than healthy non-pregnant patients. The results of these studies support the increased incidence of H. Pylori in pregnancy, but more research is still needed. Maternal implications associated with H. Pylori in pregnancy include a statistically significant higher risk for both hyperemesis, gravidarum, and gestational diabetes. Iron deficiency anemia, miscarriage, and preeclampsia have also been associated with H. Pylori. Fetal implications with maternal H. Pylori infection include an increased risk of neural tube defects in fetal growth restriction. Long-term implications are known to include Peptic ulcer disease, gastrointestinal perforations, adenocarcinoma, and gastric lymphoma. Different management techniques have been explored with the PREVPAC being the most effective and widely used in non-pregnant populations. There are currently no guidelines for H. Pylori treatment in pregnancy. Use of PPIs in the first trimester is questionable and caution is advised for amoxicillin and chlorethromycin in the first trimester. Some experts recommend differing treatment until after pregnancy. However, the complications that the infection causes during pregnancy has some providers treating once the second trimester is reached and teratogenicity is not a factor. At this point, it is provider preference to waive risks and benefits regarding treatment after the first trimester. While it has been established that there is a link between H. Pylori infection and pregnancy outcomes, more research needs to be done on increased incidence in pregnancy. H. Pylori infection and tyalism have also been observed to be closely related throughout pregnancy. However, there are no research studies to support this relationship. Finally, an optimal treatment plan or clinical guideline for patients with H. Pylori in pregnancy should be researched and developed. I still have some work to do to fine tune this paper and prepare it for publication in the Journal of Midwifery in Women's Health. I do feel that this is a very important topic and that it is underappreciated. I hope to either publish this paper or do further research on this topic in the future. Thank you and happy International Day of the Midwifery. Hi everybody, my name is Julie Patel. I'm from Boston, Massachusetts, which is located in New England. I have been a pediatric nurse for two years and I'm excited to be pursuing my dreams of becoming a midwife and caring for women. And I can't believe that I will be done with this program in December. This past spring, I completed my clinical in Manchester, New Hampshire. The clinic is a family practice, but my focus was on caring for women presenting during pregnancy. We saw patients from all over the world and of all races and ethnicities. Most women were uninsured of low socioeconomic status or presenting for care for the first time in their lives. The topic I chose for this publication assignment was on Wernicke's encyclopathy, secondary to hyperemesis gravadarm. At the beginning of this semester, I wanted to write about a common complication of pregnancy such as hyperemesis gravadarm and during my research process, I soon found that it was a very heavily studied topic with lots of great evidence. I also found that there was so much more to learn about hyperemesis gravadarm and many complications that can occur secondary to it. Many of these secondary complications are not well studied or well known and Wernicke's encyclopathy is one complication of hyperemesis gravadarm that I found interesting and one that I had never heard about. So the purpose of my keeper was to discuss the presentation diagnosis and treatment of Wernicke's encyclopathy and to provide implications for midwifery practice. I found that Wernicke's encyclopathy is a rare and acute complication of pregnancy that connects to secondary to hyperemesis gravadarm. It is a neurological emergency which is caused by a thymine deficiency in the brain and often presents as a trite of symptoms including ataxia, confusion and oculomotor changes. Thymine or vitamin B1 is a coenzyme in the body that helps with the metabolism or breakdown of carbohydrates for energy use. When pregnant women with hyperemesis gravadarm are admitted for dehydration and are rehydrated with dextrose-containing fluids, their bodies might be unable to break down the overwhelming amount of carbohydrate due to the lack of thymine which is what leads to Wernicke's encyclopathy. So Wernicke's encyclopathy is the commonly undiagnosed and can become fatal. However, with early diagnosis and treatment with IV thymine within the first 24 hours of presentation of trite of symptoms, it can be reversed. I think that there is further research that's needed for hyperemesis gravadarm as well as Wernicke's encyclopathy and good evidence to support outcomes for treatment. Currently, midwives can help prevent Wernicke's encyclopathy by screening women with hyperemesis gravadarm for symptoms of thymine deficiency such as fatigue, dizziness, irritability and mood changes and recommend increased thymine supplementation as needed. Midwives can also help with education and prevention awareness in women with hyperemesis gravadarm or in women with history of hyperemesis gravadarm as well as with their partners and families. The journal I chose to prepare this manuscript for was a journal of midwifery in women's health. I chose this journal because it is one I am familiar with and one I've had the opportunity to read and learn from during my education. It's also the journal of the American College of Nurse-Midwives, an organization that I was proud that I am proud to be a member of and it would be an honor to have my paper published in such a well-known journal. My future intent for this publication is to hopefully have it published in the journal of Midwifery in Women's Health once I'm able to finish editing it. Thank you so much for listening and happy International Day of the Midwife. Hello, my name is Jayshia Pankamy and I am currently a student at Georgetown University. I am in the CNN Women's Health Nurse Practitioner Program and will be graduating this December. I live in Maryland and I am completing my clinical rotation at George Washington University Hospital located in Washington, DC. This practice that I currently work with has 10 midwives and is a rather busy practice. This practice has a collaborative model where midwives and physicians are equal and expert partners with different skill sets to meet the needs of each woman. The topic that I chose for my publication assignment was gestational hypertension. I was interested in this topic because both my aunt and her daughter were both diagnosed with gestational hypertension during their pregnancies and I wanted to learn more about the pathophysiology, diagnostic criteria and the overall management process. Hypertensive disorders are the second leading cause of maternal and perinatal death. Midwives play a major role in the management of gestational hypertension. The role of the midwife includes screening for risk factors, early identification of pre-eclampsic symptoms and knowledge about when to collaborate, consult or refer to a physician. The goal of treatment is to prevent a seizure the most fatal complication in hypertensive disorders. Gestational hypertension is defined as a blood pressure greater than or equal to 140 over 90 developing before 20 weeks gestation and no protein protein area or severe feature associated with preeclampsia which is a more severe form of gestational hypertension. The etiology of gestational hypertension is not well known. Though some theories suggest that it is related to abnormal placental implantation and remodeling of the spiral arteries causing constriction in the blood vessels. The pathophysiology for preeclampsia on the other hand in theory is more severe and is related to abnormal placental implantation that result in endothelial damage leading to severe features that present as visual changes, epigastric pain, pulmonary edema, thrombocytopenia, renal and hepatic failure, et cetera. Currently, there's no standardized prevention strategy for gestational hypertension. Aspirin has the news for the prevention of preeclampsia due to its ability to reverse constrictive blood vessels and prevent blood clotting. This method has been suggested for the women with gestational hypertension but is not formally recommended. Studies show Aspirin has prevented IUGR and preterm rates that have shown no improved maternal outcomes of women with gestational hypertension or a high risk or women at risk to become preeclampsia. Lifestyle changes such as bed rest or salt reduction have been used in the past. However, there is not enough evidence to support these interventions. There is not a consensus on when antihypertensives should be administered. According to ACOG, antihypertensives should be given when the BP is greater than or equal to 160 over 110 because women with gestational hypertension have rare risk of cardiovascular heart failure or cerebral hemorrhage. In comparison, the National Institute for Health and Clinical Excellent Guidelines recommend the use of antihypertensives at a blood pressure of 150 over 100. There is a consensus that additional fetal monitoring should occur and include growth scans, non-stress tests, kit counts and umbilical artery Doppler testing if IUGR is expected. With increasing incidence of hypertensive disorders, there is a need for standardized guidelines that structure care. More research is needed regarding the causes of gestational hypertension, prevention strategies and ones you treat with antihypertensives. Although there is still a lack of evidence-based literature regarding, there are guidelines in place to assess and identify early signs of complications. I chose the Women's for Nursing Health Journal because I liked how this style was practical and easy for readers to interpret. I also, like for this journal, use woman-centered language and less medical driving. I intend to develop my knowledge in other nursing professional issues so that I can present information to help midwives to be aware of the knowledge gaps or significant evidence regarding those issues. Thank you and happy International Day as a midwife. Hi, everyone. My name is Erica Mathis. I am from Dallas, Texas. Midwives are present in the home birth, birth center and hospital setting within my city and the surrounding areas. However, compared to the population, there is still a great need for more midwives. Several areas of Dallas are without obstetric providers altogether. I have been fortunate enough to be completing my clinicals all at the same site that is about an hour away from me. I work with a group of eight midwives that work in private practice to provide full-scope midwifery care in office and deliver patients in a hospital setting. The midwives collaborate closely with the physician group they're in business with, allowing them to maintain care for high-risk patients. I chose my topic on management of Factor 5-Lyden in pregnancy because I personally have Factor 5-Lyden and I wanted to learn more about it. I chose the journal Nursing for Women's Health because the journal focuses on current evidence and practical implications of research. Factor 5-Lyden is implicated in a large number of obstetrical complications, including venous thromboembolism, intrauterine, fetal growth restriction, preeclampsia, personal abruption, and recurrent early pregnancy loss without a clear evidence-based association. Currently, much controversy exists within the literature and research regarding management recommendations for women with FDL. The purpose of my paper was to describe the pathophysiology of Factor 5-Lyden, discuss obstetrical complications associated with it, review and critically appraise literature and research available, and examine screening and midwifery management recommendations for women. FDL is the most common inherited thrombophilia with an incidence of one to 15% in the general population. It is an onizomal dominant mutation that increases the risk of venous thrombosis in an individual. The mutation for FDL is a single nucleotide polymorphism that prevents natural anti-coagulant mechanisms within the body. Screening and prophylactic management guidelines differ among governing bodies and on which women would be considered high-risk and appropriate for screening and treatment. American College of Obstetricians and Gynecologists currently recommend that women who are homozygous for Factor 5-Lyden and women with a history of thromboembolism be prophylactically treated in pregnancy with low molecular weight hubbren. Due to the rarity of FDL in the general population and the difficulty of diagnosis, studies that adequately test for adverse pregnancy outcomes are a challenge to produce, and it is difficult to fully associate FDL as a causal factor in obstetric outcomes that are often multifactorial. Currently, most research is retrospective in design and groups all thrombophilias together. Midwives should advocate for and participate in future research regarding this topic. The negative pregnancy outcomes that FDL may be associated with are emotional and stressful to women suffering them and their pregnancy. Often women seek justification for these outcomes and may desire screening for thrombophilias when it is not warranted or evidence-based. It is important for the midwives to view the whole picture and the whole women when providing individualized education, screening and treatment for women with FDL or with risk factors associated with thrombophilias. Midwives should also consider alternative modifiable risk factors for thromboembolism such as obesity and sedentary lifestyle when counseling women with thrombophilias. Special care should be taken to counsel women about contraception, healthy diet and exercise, preconception care and the risks and benefits of prophylactic treatment and pregnancy. It is imperative that midwives remain vigilant in seeking knowledge and new research on thrombophilia management so that they can provide evidence-based and individualized care to women with inherited thrombophilias. I feel that this is a topic that will have more research in the future. I hope to publish this paper and others at some point during my career as a midwife and I've been glad to have this opportunity to write this paper. Thank you and happy international day of the midwife. Hello everyone, my name is Christine Heinrichs. I'm a Navy nurse veteran with prior labor and delivery and postpartum experience. I live in Eastern North Carolina where I've spent the last two semesters at Campbell June Naval Medical Center OBGYN Clinic. The base serves over 25,000 people and the clinic performs roughly 3,000 visits per month. They have a very large centering program here with over 20 active groups at one time. The average age of the first-time mother here is 19 years old. North Carolina has 300 midwives across the state and attend roughly 13% of all North Carolina births. North Carolina is still fighting for independent practice and currently under a supervisory agreement. 30 out of 100 counties in North Carolina do not have an OB provider and over half of all available OBGYNs are confined to the Raleigh Durham Chapel Hill area. I chose influenza in pregnancy because I cared for a woman in her third trimester with severe influenza infection that required a several-week stay in the ICU with acute respiratory distress syndrome. Although the patient had a positive outcome, the prognosis was unclear for several weeks. She was intubated and required 24-hour fetal monitoring while on a prone rotating bed. Influenza in pregnancy is generally a mild infection for most women. However, it can become severe with certain risk factors such as asthma, obesity, smoking, cardiopulmonary disease and diabetes. The greatest concern with influenza is the development of pneumonia which can be fatal for pregnant women. Certain immunologic and respiratory changes contribute to the development of pneumonia such as increased oxygen demand by 20% and the suppressed cell mediated immunity. First trimester illness that requires hospitalization is associated with first trimester spontaneous abortion and congenital anomalies. Third trimester infection is most severe for women and the increased incidence of pneumonia is more likely. Influenza infections in the third trimester require hospitalization and they are more likely to be associated with free-term birth and stillbirth. Vaccination during pregnancy can reduce the maternal respiratory disease by 50% and reduce influenza in the newborn by 63% in infants that are under six months of age. And as most of you know, these infants are too young to receive the influenza vaccine themselves. The vaccine has been well-studied in pregnancy and has a very strong safety profile. However, only 50% of US women are vaccinated against influenza during their pregnancy. Antiviral treatment with Tamiflu is key for reducing the severity of illness when given within 48 hours of onset. It can reduce the hospital stay by four days and this is especially true for women with asthma who contract influenza. Tamiflu also has a very strong safety profile that has been well-studied. Midwives are the experts at patient education and need to share the information regarding the safety profile of both vaccines and Tamiflu and give special education for signs and symptoms of influenza to women with existing risk factors. I chose the journal Midwifery and Women's Health to submit my publication. I believe that this journal presents a lot of information that midwives can use. I'm undecided what my plans are for publication. However, I believe that more research is needed to uncover why women choose not to vaccinate during their pregnancy. Thank you and happy International Day of the Midwife. Hi, my name is Lauren Abrahamson and I'm also a midwife student at Georgetown University. I'm from the Bay Area in California and I'm training for clinicals in Northern and Southern California. The title of my manuscript is Periodontal to Disease and I was writing for the Journal of Midwifery and Women's Health clinical round section. The clinical rounds articles often include topics that can be controversial. Periodontal to Disease outcomes during pregnancy is not a new topic as many years ago. Articles will focus on the potential adverse pregnancy outcomes as well as general health outcomes associated with poor dental health. This topic remains controversial as the existing data have a strong positive correlation with adverse pregnancy outcomes associated with periodontal disease, but causality is not shown. As providers, we look for evidence-based data to provide optimal care for our women to determine what we do with strong positive correlation but not causal as it can have big impacts on the way that we practice. For example, providing oral care referrals, including dental health education and incorporating oral assessments in our physicals. These inclusions to the care we provide will cost time and money. Currently, evidence reports about 50% of women globally receive oral care during pregnancy and approximately 50% of midwives report including this in their care for women. However, the majority of midwives acknowledge the importance of oral care and good oral hygiene for women during their lifespan. Periodontal disease in any patient causes systemic inflammatory effects and is associated with diseases that are related to inflammation, for example, cardiovascular disease. The number one adverse pregnancy outcome associated with poor oral hygiene is preterm birth as well as many others. The importance for oral health extends beyond the woman to her baby. The top chronic disease of childhood is dental caries and this can get passed from the mom to the baby if oral health is neglected. Caring for the woman, caring for the whole woman is important and often the only time women seek healthcare is during pregnancy. This is a golden opportunity for midwives to comprehensively care for women and focus on disease prevention during pregnancy or otherwise. Many states provide vouchers that cover oral health care during pregnancy and if we remain informed as providers, we can share this information with the women that we care for, including the oral cavity in our assessment, understanding what periodontal disease looks like, providing education, referrals and connecting women to proper resources are ways that we can help reduce adverse outcomes associated with periodontal disease. Writing a manuscript for the journal has been a rich experience and as it feels I'm making a contribution as a professional in the field of midwifery and I plan to continue writing in the future. Thank you for your attention and happy international midwifery. Thank you so much to the wonderful students of Georgetown University's nurse midwifery women's health nurse practitioner programs for describing their work and learning about the publication process on a number of important topics. Kudos to professors, Reedy and Bowers for the creation of this assignment and their encouragement of future midwife authors. My name is Cindy Farley and I'm an associate professor at Georgetown University's nurse midwifery women's health nurse practitioner programs. I teach in the labor birth and newborn care course. I've been involved in a number of publishing endeavors including peer review and non peer reviewed articles and book chapters. I'm co-editor on two books, clinical practice guidelines for midwifery and women's health and the latest edition of prenatal and postnatal care. A woman centered approach is just out so that was a shameless plug. Thank you very much. I'd like to share some of my learning about the publishing process with you. Some of it earned through the school of hard knocks. Even accomplished authors will often have their work revised or rejected from time to time but not to worry we learn as much from our failures as we do from our successes. So for students considering publication, first and foremost, you need to transform your manuscript submitted as a school assignment. Even if your teacher praised your paper as the best she has ever seen, gave it an A and wants you to send it to the most prestigious journal, it's still quite likely to read more like a school assignment than a publishable manuscript. Remember that your teacher needs to see your thought process in a more detailed way than most audiences you will write for. And school papers tend to have more generous word limits than most journals do. It is best to consider that you will end your course assignment with a solid rough draft of a manuscript that will likely need several revision cycles before it is ready to submit. This takes time and commitment beyond the course that was written for. Can you invest that sort of dedication to publish? You need to consider several things as you move forward with your revision process. What is your message, your perspective on the topic? The midwifery perspective is often underrepresented in the literature. For example, the idea that labor pain should be eradicated is one perspective often espoused in medical literature but midwives bring to the table the idea that pain is part of the process that can be ameliorated, can be coped with and is really only one part of the process important to a woman's well-being and satisfaction with her labor and birth experience. The midwifery perspective is an important addition to the conversation for many types of audiences. Think about getting to your midwife colleagues through midwifery journals but also consider other disciplines that need to hear from us, physicians, anesthesia personnel, nurses, educators. The public also benefits from awareness about midwifery. So look beyond professional journals and consider whether you can tailor your message to a wider audience. Think about how you will edit your language for a particular audience. I have more advice but we have very limited time so I do wanna truncate my talk a little bit. I'm gonna say definitely you might wanna consider a query letter to the editor to see if they're interested in your topic for publication. This is a simple letter or email that's asking them of their interest. They might have had a recent article published and therefore not looking for that particular topic at this time. You really want to pay attention to the journal criteria. You don't wanna submit more words than they're asking for. You want to make sure the references are current and the reference style used is correct. The order that you present your ideas is important and as you review your work for clarity, be sure to read it out loud to catch errors and check for coherence. Ask a peer to review it for you. A peer not afraid to give constructive feedback. And finally consider inviting your faculty to co-author your manuscript with you. Faculty are under pressure to publish and working as a dynamic duo can be motivating for both of you. And that will conclude our third annual Georgetown Virtual International Day of the Midwife Student Cafe. You can find archival presentations of our 2016 and 2017 student cafes on the Virtual International Day of the Midwife. Website and I wanna wish everyone a happy International Day of the Midwife and we hope to see you next year. Are there any questions in the audience? There were some really great comments and questions in the chat and what I can do with that is I can send you, I've saved a copy of it, Cindy and I can send that along to you and you can share that with the students. They may want to connect with Irene. She's doing some amazing work in China and her presentation was last evening. Well, we noticed her comments and we will respond. So thank you Irene, thank you Esther and Nancy and thank you so much, Lorraine. It's been a pleasure. It's been a pleasure as always. And this is your three I believe for our student cafe with Georgetown. It certainly is and we've enjoyed it. Terrific. The recording should be available shortly, just the rough recording and then we'll be putting them on YouTube probably early next week. All right. There they are. All right. They are the best, they are absolutely the best. A great group. All right, happy International Day of the Midwife.