Postpartum Haemorrhage - the Physical and Psychological Impact on the Affected Woman and the Ideal Follow-Up Care 18

FLORENCE NETWORK STUDENT NEWSLETTER 7 AUTUM 2015 CONTENT

3. Hi from the Student-board 4. Meet the new president 5. The nursing university system in Scotland 6. An Erasmus-experience 7. Florence Network 23rd annual meeting in Copenhagen 10. From student to nurse 11. Nurse-student and volunteer at the Florence Network annual meeting 13. Postpartum haemorrhage - the physical and psychological impact on the affected woman and the ideal follow-up care 18. Closing Karoline Hasle Einang, Norway Hi from the student-board

Hi, everyone! It is with great Give it a thought, talk to your FLECO pleasure that I, on behalf of the and let us know if there is anything board, welcome you to the new you want to know about the spots. Florence Network student-board annual newsletter. It is packed As we are getting ready for our with letters, articles and meeting, the United Nations have interesting things from our agreed upon the new millennium student-members. Please enjoy development goals. Three of these and share this with your fellow goals are about health, and others students and schools. We want to about matters that impacts and are be seen! impacted by health: - Goal 4: Reduce child mortality. - Goal 5: Improve maternal health. - Goal 6: Combat HIV/aids, malaria and other diseases. As a international network of nurse- and midwife students, teachers and lecturers we have a responsibility to promote these goals and do our part to realize them. Lets use our next meeting to discuss and share The student-board is getting thoughts on how these issues can be ready to go to Italy to plan our faced. next annual meeting in Verona, in april. We will see the city, plan The student-board is looking our meetings, workshops, food forward to seeing you again at and accommodations. Let us Florence Network annual meeting know if there is anything you 16, in Verona. Take care, be good really want to include in the next students, have fun and see you soon! FNAM. Being a part of the student-board is a great privilege, Hugs from the student-board; Simon and so much fun; you should try Dauding, Florian Van Garderen, it! This spring we have four open Karoline Hasle Einang, Ines Neukom spots in the board, including the and Nicole Tumble Forbes. presidency. 3 Simon Dauding, Denmark Meet the new president of the student board

Hello Everyone, to question how we practice A bit about myself, my name is our profession in our home Simon Dauding I’m 25 years old country compared to other and I am a nurse student on my countries. final year at Metropolitan University College, Copenhagen. I believe the student board is an Along side my study, I work at important part of the Florence Metropolitan University College as network and a way for the an international student counselor students to communicate with where I help other students to apply the rest of the board. for exchange, which was the reason I got to learn about the Florence We in the student board has Network. already begun working towards next year’s Florence meeting Academically, I am interested in the and I’ll encourage all of you psychiatry and find this part of students to contact us if you nursing incredibly challenging. have feedback from the meeting When I graduate I think I’ll try to in Copenhagen or good ideas combine my two interests, the for next year’s meeting in international work and the Verona. psychiatry and see where it takes me.

I applied for the Presidency of the student board because I find the international work interesting and because I think Florence Network has the ability to challenge students to be innovative and to inspire us

4 Nicole Forbes, Scotland The Nursing University System in Scotland

At Glasgow Caledonian Scottish students are not required to University, the student nursing pay student fees for their course and system differs from other they also receive a bursary for countries as students have the studying nursing. I am currently in choice to specialise in a particular my second year at university and I type of nursing, before they start study Child Nursing. their course. The options available are Adult, Child, Mental I personally prefer the fact that we Health and Learning Disability have the option to specialise Nursing. The duration of each beforehand as it has been of great course is full time for three years benefit to me. I have always had a and students will graduate with a great desire to work with children Bachelor of Nursing. and child nursing is the only type of nursing that I was interested in Each nurse is expected to carry specializing in. Having worked on out 2300 hours of practice various other types of Adult Nursing placement experience. The course wards, this area did not appeal to is split 50:50 so that students me. I now study a course that I know spend an equal amount of time I am extremely passionate about and on placement as they do in I am gaining a wealth of experience practice. working in a range of Child Nursing wards. In order to meet the requirements of the Nursing and Midwifery The extra time that I have spent on Council for Nurse Education, the the child wards has allowed me to course operates on an extended feel more prepared and confident for academic year of 45 weeks for the future. each of the three years of study. During the summer, nursing students do not have a full summer vacation; instead we spend our time on placement in the hospital.

5 Karoline Hasle Einang, Norway An Erasmus- experience

Im Karoline, and I just finished my Eramus-exchange in Udine, Italy. I did my surgical placement in a ward for orthopedics and trauma for ten weeks, as a part of my second year in nursing. These ten weeks have been hard, interesting and so rewarding. I have learned so much about nursing, about Italy, and about myself.

Living alone in a new country was quite scary, but I quickly made friends from all around Nursing in Italy is quite similar to Europe, became more self- nursing in Norway. You have confident and started my about the same standards of placement in the hospital. I equipment and a lot of the same usually find placements really diseases and issues. I believe the exhausting even in Norway; there biggest difference is the workload is so much to learn and you really and salary, the nurses in Italy want to make a good work more for less. Italy also has performance. Since I can´t speak a lot more male nurses than we much italian, it proved even do in Norway, good job Italy! harder because I tried to understand a new language and I am so pleased with my Erasmus- often had to interpret what was experience. I have learned so going on in the ward. On the much, made a lot of good friends other hand; I have learned so and as cliché as it sounds; I have much because of the language- grown as a nurse, and as a barrier. I have practices my non- person. I have made a great verbal communication-skills, and friend in my self as well. have used a lot of time to practice practical procedures. Also communication with patient through a interpreter is something to practice. 6 Valerija Roos, Switzerland Florence Network 23rd annual meeting in Copenhagen

Sometimes when I think back to The first day at Metropolitan the time we spent in University College was meant for Copenhagen, I become very us to arrive and get to know each nostalgic. Whereelse do you get other in “Café Koma”. This was the chance to meet so many new where I had great conversations people in your age, interested in about the Danish nursing and the same things as you are midwifery study system and met interested in? Florence Network students from different European Annual Meeting is a great countries. Socializing is about opportunity to get to know talking, building new friendships young people from all over and spending an unforgettable Europe, exchange informations time together. and experiences and make new acquaintances. The next day started at 08.30 am. This morning continued with We spent five days (13.04.15 - several presentations 17.04.15) in Copenhagen, such as “Falling into the light“ and primarily in the Metropolitan “Development of Fall Detection University College, where we Technology: a Nurse-led slept and lived, having a well- Usercentered Approach“. At the organized program but also beginning I was eager to write getting the chance to see some everything down and act as I was parts of Copenhagen itself. used to act when I am in a lecture. But I quickly realized that FNAM is not about studying for an exam or knowing everything a lecturer said; it’s about being open- minded and interested in different study- systems and cultures 7 Valerija Roos, Switzerland Florence Network 23rd annual meeting in Copenhagen

So I just enjoyed and let the very impressive movie about informations flow through me. prejudices and ideas about In the afternoon we had different cultures. In the different workshops and split up afternoon we had some into small groups. We had the workshops and discussions. I chance to exchange a lot of visited the workshops to informations and discuss with “Internationalization at Home: other students and lecturers. In Solutions instead of limitations. the late afternoon we enjoyed a What are the challenges?” and beautiful Canal Tour in “Quality in International Copenhagen. Exchanges - How and what should we measure?” These workshops really opened my eyes and gave me a new opinion about exchanges during my time as a student.

In my point of view the most interesting part of FNAM happened the last official day. We had the unique opportunity to visit different hospitals. Wednesday we went to Because I am a midwife-student, University College Zealand in I decided to go to Herlev’s labour Roskilde. I must say the lecture ward. It was so exciting to hall we were in really impressed compare this labour ward with me. It was wonderful and so the ones I know in Switzerland. modern. We had several lectures such as “What competence will European health care professionals need in the future?“ or “Intercultural Communication“ and watched a 8 Valerija Roos, Switzerland Florence Network 23rd annual meeting in Copenhagen

Thursday evening we had a On the last day we went to the special occasion: a Gala Dinner. Shakespeare’s Castle. A guide We had to get dressed-up. Our showed us the Castle from the very in-house chef gave his best to top to the deepest caves spoil us with the amazing underground. This was a strong tasting smørrebrød, salmon and insight into Denmark’s history. meat. After dinner a band These five days passed so fast, but as played so we could dance. The I said at the beginning: Everytime I atmosphere was so relaxed and think back to Copenhagen and its carefree. A wonderful conclusion memories I get nostalgic. I just of an extraordinary experience. wished these days did not pass that fast. I made a lot of experiences, changed my opinion about some things and met great people.

Thanks to everyone for these five days

9 Madelén Snørteland, Norway From student to nurse

I can`t believe I’ve been a This is one of the reasons why I registered nurse for a whole wanted to become a nurse in the year. Well, actually its been 378 first place. On the other hand, the days! 378 days of challenges, trust that my patients have in me opportunities and lots of new is scary. Im still a little afraid of knowledge. Last year I was saying or doing something wrong. staring at the start of my new But this is all part of being a nurse. life. I was really insecure and There are loads of new things to nervous about being a nurse. I learn each day. No diagnosis is the kept asking myself questions like same, no patient is the same. And “do I know enough to work on my by becoming a registered nurse own?” “How will I act if you will learn to differentiate and something happens to my make your day and your career patients?” “Am I good enough?” what you want it to be. To start off, no I did not know enough when I started working. Be the nurse you know you are. Cause nursing is a work of heart! I had loads of questions, many of Now I look at those in the same which I probably should know the situation as I was last year and I answer too. But I was incredibly envy them. I envy the start of an lucky to have amazing colleagues amazing career with lots of to lean on, and they helped me challenges and new things to become the nurse I am today. learn. For those of you who just Going from being a student to graduated good luck on your new becoming a registered nurse is career and welcome as fellow difficult. I thought it would be nurses. And for those of you still quite similar as being student but studying, keep up the good work! I was wrong. Having my patients The tassel`s worth the hassle, good depending on my and trusting luck! everything I say and do is Sincerely Nurse Madelén sometimes the best thing in the world. I feel like I really matter to them. I help people in a difficult time of their lives.

10 Frederikke Marie Sørensen, Denmark Nurse-student and volunteer at the Florence Network annual meeting

In my spare week after my exam, I We had a social event all the was attending the Florence Network students together. Everybody was Annual Meeting (FNAM) as a student supposed to bring some food and/ volunteer without knowing what I or drinks from their home country. should expect at all because I had We ate a lot and tasted different never heard about the network kind of foods and we did a lot before. I was quite excited, even mingling in between. Then we had though a lot of my friends thought it a huge amount of pizzas from the was kind of nerdy now we finally local pizzeria. Everybody was so was off from school. I got to know full of food and happy! The about the conference at a “welcome studentboard had arranged a quiz back-meeting” in November. I have battlegame where we got divided been in Shanghai for two months to into smaller groups, the questions do an internship there. Our was of course about nurse – and international student staff Simon told midwife stuff and we had a lot of us about it, and I decided to sign up fun. for it with a friend.

The first day started with a short briefing about the program of all week. Afterwards we walked around the school to check and to assure that the classrooms were ready to receive all of the visiting students from around Europe. Our job was to check-in the students, and to show them around the school, their home during the conference. We went all together to our student bar “Coma” It was such a great night and a to eat, have a beer, and just to pleasure to meet everybody. welcome everybody and have fun together. The third day we went to Roskilde by taking the long red FNAM-bus. The next day was packed with We visited University College different workshops; unfortunately I Zealand where we attended was not able to attend that. I joined workshops during the day. later in the evening. 11 Frederikke Marie Sørensen, Denmark Nurse-student and volunteer at the Florence Network annual meeting

It was very interesting and it gave an dresses and high heels in our bags. insight and a perspective to the We had a fantastic evening, international challenges we have in students and lecturers together. our healthcare system around the Delicious food, Danish beers, world. Such as; demographic entertaining and dancing! changes, more people with chronic diseases, aging population and more. We went to Helsingør Friday for a “Together we are stronger” was the social trip to visit the Castle most powerful and best point line Kronborg in Helsingør. It was such from a seminar, that I have got a nice way to be together for the printed in my mind. During last day and of course it was sad Thursday morning the participants when we came to say goodbye. went to visit different Hospitals Hopefully it was only a “see you departments in Copenhagen. A lot of again – goodbye”. So as a student the students told me that it was very nurse and a volunteer to FNAM I exciting for them to see and compare really recommend all to apply to be the differences between their a volunteer in their home country Hospitals in their home countries to or of course to attend and be apart the Danish Hospitals and to talk with of FNAM. The week was both social the nurses and midwifes there. and professional inspiring to me. Without knowing anything about Thursday was also the day where the the network and without any student board held a meeting. They expectations it ended up to be an also did a votation to find a new unforgettable experience. It gave president, since Anton former me a lot of sweet and interesting President from Sweden, will be a international nurse and midwife graduated (and an awesome) Nurse friends around Europe and also a next year. Simon from Denmark, my wide knowledge about my fellow student who got me into the profession and its international conference he won, congratulations aspects. I hope to be able to attend Simon! In the afternoon I did some FNAM next year in Verona and to preparing work together with other see as many as possible from this volunteers and the school canteen to year and of course many new get ready for “the big gala-dinner”. FNAM’ers. We were so lucky as volunteers that we also could attend the gala-dinner and for that reason we brought 12 Ines Neukom, Switzerland Postpartum haemorrhage – the physical and psychological impact on the affected woman and the ideal follow-up care Bachelor thesis 2015, Zurich University of Applied Sciences (ZHAW), Ines Neukom Accompanied by Elisabeth Spiegel-Hefel, lecturer at the Institute of Midwifery, ZHAW

Abstract which is a risk factor for having a Several studies demonstrated PPH 6,7. increasing rates of postpartum haemorrhages (PPH). With this trend, A PPH can be mortal and when it the topic achieves more and more does not kill, it can have a severe relevance. The massive loss of blood is physical and psychological impact on a severe incident and in serious cases the affected woman. This can also it can be fatal. In several other cases a have a negative effect on the affected PPH can lead to severe consequences. woman’s family 8. The physical and Currently only a few studies exist psychological impacts of a PPH about that issue. The Bachelor thesis therefore deserve appropriate of Ines Neukom, which forms the basis attention. of this article, summarises the current state of knowledge. The aim of this Bachelor thesis was to illustrate the physical and Introduction psychological impact of a PPH on the “... I’d lost so much blood so quickly, I affected women – using evidence- was dying, basically, and could feel based literature- and to formulate myself dying and sort of slipping recommendations for an effective away ...“ 1. follow-up care.

Those are the touching words of a Method woman who remembers the dramatic A literature research was conducted moments after the delivery as she by using the databases Medline, nearly lost her life due to a severe loss Midirs, Cochrane Library, PubMed of blood. und Psycinfo. Using predefined keywords, five studies have been A postpartum haemorrhage is a life- selected of which four were threatening complication and one of qualitative and one quantitative. The the main causes of maternal studies have been analysed and morbidity and mortality worldwide discussed critically. Furthermore 2,3. PPH occurs in around 0.5 - 5% of literature from the university library births in developed nations 3,4. was used. In addition a survey Regarding a Canadian study the PPH- concerning follow-up care guidelines rate increased by 27% in the years for women after PPH has been 2000 to 2009 3,5. A possible reason conducted. The survey will be for this trend could be the increasing described later in this article. rate of medical inductions of labour, 13 Ines Neukom, Switzerland Postpartum haemorrhage – the physical and psychological impact on the affected woman and the ideal follow-up care Bachelor thesis 2015, Zurich University of Applied Sciences (ZHAW), Ines Neukom Accompanied by Elisabeth Spiegel-Hefel, lecturer at the Institute of Midwifery, ZHAW

Results This can cause an agitated child who The results of the Bachelor thesis have cries excessively. That can provoke shown that a PPH can have a serious psychological stress in the mother physical and psychological impact on and can have a negative influence on the affected woman and that midwives the lactation. A consequence can be can contribute to health promotion and self-reproaches. This again intensifies prevention by undertaking preventive the psychological stress and therefore and therapeutic tasks. An appropriate results in a vicious circle. Those compilation of possible physical and vicious circles must be interrupted. psychological consequences is Starting points for the work of illustrated in table 1. midwives can be found exactly here.

The analysis of the literature has Recommendations for practice shown that the single consequences can Detailed recommendations for interact, influence and intensify each practice have been formulated. other and therefore can result in a Appropriate information given to the vicious circle. This is demonstrated in affected woman and support in the following chart (fig. 1, next page). everyday life with her child are Due to physical fatigue it is often not essential. Furthermore particular possible for the mother to care for her attention should be paid to the child sufficiently. relationship between mother and child as well as to breastfeeding after PPH.

Table 1: Potential physical and psychological impact of a PPH on the affected woman

Physical impact Psychological impact • Longer postnatal bleeding duration • Traumata • Higher risk for uterine infections • Disturbed bonding of mother and child • Higher rate of hospital readmission • Postnatal Depression (PND) • Fatigue • Post-Traumatic Stress Disorder (PTSD) • Breastfeeding problems • Disempowerment of the women if the need of information is not considered • Sexual problems • Effects on reproduction and following pregnancies • Problems in the relationship with the partner • Persistent anxiety • Development of hospital- and blood-phobia

14 Ines Neukom, Switzerland Postpartum haemorrhage – the physical and psychological impact on the affected woman and the ideal follow-up care Bachelor thesis 2015, Zurich University of Applied Sciences (ZHAW), Ines Neukom Accompanied by Elisabeth Spiegel-Hefel, lecturer at the Institute of Midwifery, ZHAW

A complete compilation of the most Equivalent, written guidelines could important recommendations and tasks valuably contribute to a minimization for experts who work with affected of the physical and psychological women can be found in the “checklist consequences of PPH. Affected women for tasks after PPH” at the end of this could be saved from unnecessary article. suffering. Therefore the author designed a checklist that manages the Discussion handling of women after PPH in the The bachelor thesis shows which kind first hours and days as well as after of consequences a PPH can have and discharge from hospital. The checklist which tasks can be undertaken to can be used interprofessionally and at minimize those consequences. The the same time serves as an overview question to what extent follow-up care and documentation which guidelines for women after PPH exist in information already has been given practice came up. and which interventions have been executed. The checklist is based on the To clarify this question, the author findings that have been extracted conducted a not-representative survey from the theoretical background and including the hospitals with the highest the analysed studies listed next page. birth rate within German-speaking Switzerland, which showed the following result: All hospitals (n=11) answered that they are not having any written guidelines for the handling of women after a PPH. Several hospitals evinced that there is a need of such guidelines. Some of them mentioned that every woman on their maternity ward is asked about her emotional and physical well being, that support is offered and physiological and physical consequences after a PPH are discussed. However in none of the consulted hospitals this approach is put down in writing. Fig. 1: Physical primary consequence with psychological and physical secondary consequences, illustration by the author Copyright© Ines Neukom

15 Ines Neukom, Switzerland Postpartum haemorrhage – the physical and psychological impact on the affected woman and the ideal follow-up care Bachelor thesis 2015, Zurich University of Applied Sciences (ZHAW), Ines Neukom Accompanied by Elisabeth Spiegel-Hefel, lecturer at the Institute of Midwifery, ZHAW

16 Ines Neukom, Switzerland Postpartum haemorrhage – the physical and psychological impact on the affected woman and the ideal follow-up care Bachelor thesis 2015, Zurich University of Applied Sciences (ZHAW), Ines Neukom Accompanied by Elisabeth Spiegel-Hefel, lecturer at the Institute of Midwifery, ZHAW

References

Studies analysed in the bachelor thesis:

Elmir, R., Schmied, V. & Wilkes, L. (2012). Between life and death: women’s experiences of coming close to death, and surviving a severe postpartum haemorrhage and emergency hysterectomy. Midwifery, 28, 228 – 35.

Sentilhes, L., Gromez, A., Clavier, E., Resch, B., Descamps, P. & Marpeau, L. (2011). Long-term psychological impact of severe postpartum hemorrhage. Acta obstetrica et gynecologica Scandinavica, 90, 615 – 620. doi:10.1111/j. 1600-0412.2011.01119.x.

Snowdon, C., Elbourne, D., Forsey, M. & Alfirevic, Z. (2012). Information-hungry and disempowered: a qualitative study of women and their partners’ experiences of severe postpartum haemorrhage. Midwifery, 28, 791-799.

Thompson, J. F., Roberts, C. L. & Ellwood, D. A. (2011). Emotional and physical health outcomes after significant primary post-partum haemorrhage (PPH): a multicenter cohort study. The Australian & New Zealand journal of obstetrics & gynaecology, 51, 365 – 371. doi:10.1111/j.1479-828X.2011.01317.x.

Thompson, J. F., Ford, J. B., Raynes-Greenow, C. H., Roberts, C. L. & Ellwood, D. A. (2011). Women’ s Experiences of Care and Their Concerns and Needs Following a Significant Primary Postpartum Hemorrhage. Birth: Issues in Perinatal Care, 38(4), 327 – 335.

Studies cited in the article:

1 Elmir, R., Schmied, V. & Wilkes, L. (2012). Between life and death: women’s experiences of coming close to death, and surviving a severe postpartum haemorrhage and emergency hysterectomy. Midwifery, 28, S. 230.

2 Oyelese, Y., Scorza, W. E., Mastrolia, R. & Smulian, J. C. (2007). Postpartum hemorrhage. Obstetrics & Gynecology, 34(3), 421 – 441.

3 Hösli, I. & Gezer-Dickschat, S. (2014). Postpartale Hämorrhagie. Hebamme.ch, 9, 4.

4 Surbek, D., Irion, O., Hess, T. & Drack, G. (2009). Expertenbrief No. 26. Kommission Qualitätssicherung. Präsident Prof. Dr. Daniel Surbek. Aktuelle Therapieoptionen der postpartalen Hämorrhagie (actualized version of 3.11.2009).

5 Mehrabadi, A., Hutcheteon, J. A., Lee, L., Liston, R. M. & Joseph, K. S. (2012). Trends in postpartum hemorrhage from 2000 to 2009: a population-based study. BMC Pregnancy Childbirth, 12, 108.

6 Hösli, I., Vökt, C., Lapaire, O., Girard, T. & Gisin, S. (2014). Skript Geburtshilfliche Notfälle.

7 Mächler, A. & Wettstein, S. (2014). Postpartale Hämorrhagie nach Geburtseinleitung – Gefahr oder Mythos? Empfehlungen zur Überwachung des mütterlichen Blutverlustes nach einer Geburtseinleitung. Bachelorarbeit. ZHAW, Departement Gesundheit, Winterthur.

8 Boyle, M. (2011). Emergencies around childbirth: a handbook for midwifes (2. edit.). London: Radcliffe Publishing.

List of figures:

List of tables:

17 Closing

The Florence Nursing and Midwifery Please contact us at any time on Network consists of 37 universities and [email protected] and follow us schools of higher education in 18 Europe- on Facebook "Florence Network - Student an countries and is one of Europe’s oldest board". nursing and midwifery networks. It´s main goals include raising the profile of Big hugs from the Student board! European Nursing and Midwifery, stimulating and organising the exchange of lecturers and students, comparing and developing new curricula in Nursing and Midwifery education in Eu- rope, stimulating research and developing common projects and activities within SOCRA-TES, ERASMUS and other pro- grammes. The Network promotes the involvement of students, educators, practitioners and policy makers to ensure strong links between theory, strategy and practice. The student board are a group of current nursing and midwifery students, studying in various different European countries. We work as a team within the Florence Network, promoting cooperation and communication between students and lecturers, ensuring that the Network is visible in universities and schools of higher education and encouraging international student exchange, as well as taking responsibility for and contributing to the achievement of exchange stu-dents’ learning outcomes.

We really hope you have enjoyed the Florence Network student-board newsletter 2015. We hope to see you again in Verona, Italy, for Florence Network annual meeting 2016.

Pictures by Valerija Roos