Combined Modules 1-7
1. The changing patterns of women's alcohol use
Presentation
Presenter: Marilyn Pierce-Bulger, MN, FNP, CNM Length: 23 minutes
American women consume alcohol in larger quantities and higher frequencies than in previous decades. Health care providers often hesitate to address alcohol use with patients seen in practice. This webinar reviews alcohol use trends among women and how they relate in particular to women of reproductive age.
Access at www.npwh.org/courses/home/details/823. Registration may be necessary.
Learning objectives
Discuss the changing patterns of alcohol use of American women.
Review unintended pregnancy rates in the U.S.
Discuss the potential impact of alcohol use on reproductive health and unintended pregnancies.
Supplemental readings
Bray BC, Dziak JJ, Lanza ST. Age trends in alcohol use behavior patterns among U.S. adults ages 18–65. Drug and Alcohol Dependence. 2019;205:107689 .
Denny CH, Acero CS, Naimi TS, Kim SY. Consumption of alcohol beverages and binge drinking among pregnant women aged 18–44 years - United States, 2015–2017. Morbidity and Mortality Weekly Report. 2019;68(16):365–368.
Kanny D, Naimi TS, Liu Y, Lu H, Brewer RD. Annual total binge drinks consumed by U.S. adults, 2015. American Journal of Preventive Medicine. 2018;54(4):486-496.
White A, Castle IJ, Chen CM, Shirley M, Roach D, Hingson R. Converging patterns of alcohol use and related outcomes among females and males in the United States, 2002 to 2012. Alcoholism: Clinical and Experimental Research. 2015;39(9):1712-1726 .
Discussion questions
Discuss how changing patterns of alcohol use in the U.S., and particularly among women, can potentially influence pregnancy outcomes.
What trends have contributed to this change?
How can preventive health messages be delivered effectively to this group?
Downloads
Continuing Education - CDC Health Professional Online Training for FASD Prevention.pdfFree online FASD training courses for health professionals
ABCs of Binge Drinking american college of cardiology.pdfThe ABCs of binge drinking
AEP_NPWH Position Statement.pdfNPWH Position Statement - Prevention of Alcohol-Exposed Pregnancies
JUNE_2020_WH-Clinical-resources.pdfClinical Resources - Nurses and midwives: Partnering to prevent FASDs
2. Alcohol - The teratogen
Presentation
Presenter: Carolyn Shaputnic, RNC-NIC, MPH Length: 19 minutes
The teratogenic effects of alcohol use during pregnancy have been well-established in the research literature. This webinar reviews relative findings and discusses known effects of alcohol on a developing embryo and fetus.
Access at www.npwh.org/courses/home/details/824. Registration may be necessary.
Learning objectives
Describe how alcohol can affect the developing fetus.
Define FASDs.
Define teratogen.
Discuss why the recommendation is for no amount of alcohol during pregnancy, planning pregnancy, or breastfeeding.
Suggested supplemental readings
Coles CD. Critical periods for prenatal alcohol exposure: Evidence from animal and human studies. Alcohol Health and Research World. 1994;18(1):22-29.
Suggested handouts
Fetal development chart (English)
Suggested activities or assignments
Teratogens are powerful agents known to compromise typical pregnancy and fetal development resulting in birth defects and/or abnormal or impaired behavior. Based on the four categories of teratogens, develop a list of teratogens and indicate which are within an individual’s ability to control. How might the teratogenic effects of alcohol use be included as a routine discussion during clinical care?
Reducing exposure to toxic environmental agents is a critical area of intervention for women’s health nurses. Develop and discuss a list of challenges to address alcohol use among women of reproductive age, including societal and individual benefits.
Downloads
Fetal Dev Poster_HOR_11x8.5-2.pdfFetal development chart
(English language version)
(English language version)
Fetal Dev Poster_HOR_11x8.5-2_SPL.pdfEl alcohol y el embarazo no se mezclan
3. Alcohol: The teratogen - Neurobehavioral impacts
Presentation
Presenter: Marilyn Pierce-Bulger, MN, FNP, CNM Length: 20 minutes
This webinar describes a known clinical set of outcomes associated with prenatal alcohol exposure. Recognition challenges are discussed.
Access at www.npwh.org/courses/home/details/825. Registration may be necessary.
Learning objectives
Review the current prevalence of FASDs.
Describe the continuum and potential impact of the effects of prenatal alcohol exposure (PAE) on a child’s functional and behavioral presentation.
Identify challenges related to the early recognition of FASDs.
Suggested supplemental reading
Bertrand J. Fetal alcohol spectrum disorders are clearly brain-based. Developmental Medicine & Child Neurology. 2016;58(8):794-795.
Suggested handouts
Impacts from prenatal substance exposure
Research summaries – impacts of alcohol on child development
Suggested videos
What is FASD? Length: 1:16 minutes
Marilyn Pierce-Bulger, CNM, gives a brief overview of fetal alcohol spectrum disorders.FASDs: Beyond Physical Effects Length: 2:55 minutes
Fetal alcohol syndrome is one of the most well-known indicators of damage caused by drinking alcohol during pregnancy, but most of the effects are not visible. Marilyn Pierce-Bulger, CNM, discusses some of the less obvious signs and effects of prenatal alcohol exposure.Drinking While Pregnant: What Happens to the Baby Length: 3:56 minutes
This video discusses the effects of alcohol on a baby in the early stages of pregnancy and throughout development.
Downloads
Impacts from Prenatal Substance Exposure.pdfImpacts from prenatal substance exposure
Research Summaries - Impacts of Alcohol on Child Development.pdfResearch summaries
4. Routine Alcohol Screening
Presentation
Presenter: Marilyn Pierce-Bulger, MN, FNP, CNM Length: 24 minutes
Recommended guidelines for alcohol use among women are often lower than individuals may expect. According to CDC, only one in six patients discuss personal alcohol consumption with a healthcare provider. This webinar introduces the AUDIT (U.S.), a validated alcohol screening instrument used to effectively understand a patient’s alcohol use.
Access at www.npwh.org/courses/home/details/829. Registration may be necessary.
Learning objectives
Describe an evidence-based alcohol screening tool.
Describe recommended alcohol use guidelines for women.
Suggested supplemental readings
Finnell DS, Nowzari S, Reimann B, Fischer L, Pace E, Goplerud E. Screening, Brief Intervention, and Referral to Treatment (SBIRT) as an integral part of nursing practice. Substance Abuse. 2014;35(2):114-118.
McKnight-Eily LR, Okoro CA, Mejia R, et al. Screening for excessive alcohol use and brief counseling of adults - 17 states and the District of Columbia, 2014. Morbidity and Mortality Weekly Report. 2017;66(12):313-319.
Position statements
American College of Nurse-Midwives. Position statement: Screening and brief intervention to prevent alcohol-exposed pregnancy. American College of Nurse-Midwives. 2017.
Nurse Practitioners in Women's Health. Prevention of alcohol-exposed pregnancies. Women's Healthcare. 2016;4(4).
Association of Women's Health Obstetric and Neonatal Nurses. Optimizing outcomes for women with substance use disorders in pregnancy and the postpartum period. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2019;48(5):583-585.
Suggested handouts
US AUDIT with instructions & scoring
Selecting an alcohol screening instrument
Suggested activities or assignments
Peer-to-peer US AUDIT role play – 10 minutes to set up and complete
Find a partner. Choose one of the following character profiles. Consider how your character might answer the AUDIT screening questions.
Character profile # 1 drinks alcohol 4 times each week
Character profile # 2 has 3 standard drinks containing alcohol on a typical day when drinking
Character profile # 3 has 4 or more standard drinks containing alcohol on one occasion once a month
Decide which of you will be the client first and which will be the clinician.
Clinician: Your task is to administer the AUDIT with your client by reading through the 10 questions and determining scores based on the answers provided.
Client: Don’t tell your partner which character you are choosing. Your task is to respond to the AUDIT questions as your character might respond.
Take no more than 3 minutes and then switch roles and repeat the role play again taking no more than 3 minutes.
Take 3 minutes to process with each other how it felt to ask the questions and how it felt to answer the questions. Were you uncomfortable with any of the questions? How do you think actual clients might feel?
Downloads
Alcohol SBI Fact Sheet.pdfAlcohol screening and brief intervention fact sheet
AUDIT1-3 with AUDIT US and Scoring Instructions.pdfUS AUDIT
Selecting An Alcohol Screening Instrument.pdfSelecting an alcohol screening instrument
5. Brief intervention - A practical response to alcohol screening
Presentation
Presenter: Marilyn Pierce-Bulger, MN, FNP, CNM Length: 22 minutes
Effectively addressing alcohol use as part of preconception care can include several types of interventions. Three types of brief interventions to prevent alcohol-exposed pregnancies are discussed in this webinar.
Access at www.npwh.org/courses/home/details/830. Registration may be necessary.
Learning objectives
Review how to determine risk for alcohol-exposed pregnancies.
Discuss practical responses to alcohol screening.
Suggested supplemental reading
Chiodo LM, Cosmian C, Pereira K, Kent N, Sokol RJ, Hannigan JH. Prenatal alcohol screening during pregnancy by midwives and nurses. Alcoholism: Clinical and Experimental Research. 2019;43(8):1747-1758.
Kelsey B, Edwards A, Pierce-Bulger M. Nurses and midwives: Partnering to prevent FASDs. Women’s Healthcare: A Clinical Journal for Nurse Practitioners. 2020;8(3):25-27 .
Shogren MD, Harsell C, Heitkamp T. Screening women for at-risk alcohol use: An introduction to screening, brief intervention, and referral to treatment (SBIRT) in women's health. Journal of Midwifery & Women's Health. 2017;62(6):746-754.
Suggested handouts
US AUDIT with instructions & scoring
Screening tool comparison chart
Suggested activities or assignments
The media can skew our understanding of federal guidelines (www.cdc.gov/ncbddd/fasd/alcohol-use.html) and other research for preventing FASDs. Discuss the following blog posts 1) bit.ly/2iCacSd; 2) bit.ly/1nMoVa9; 3) bit.ly/2ySw7c1. Generate ideas on how to respond appropriately to clients seen in clinic who refer to these opinions regarding alcohol use during pregnancy.
Peer-to-peer brief intervention role play – 15 minutes to set up and complete
Find a partner. Read both the scenarios and decide who will be the client and who will be the clinician for each one.
Scenario # 1: At a routine well-woman visit you ask a sexually active, reproductive age client the one key question – Would you like to become pregnant in the next year? She answers no. She is not using contraception. She has 2-3 beers about one weekend a month and her audit score overall indicates low risk alcohol use.
Scenario # 2: At a routine well-woman visit you ask a sexually active, reproductive age client the one key question – Would you like to become pregnant in the next year? She answers yes. She is not using contraception. She has 2-3 beers about one weekend a month and her audit score overall indicates low risk alcohol use.
Decide which of you will be the client first and which will be the clinician.
Clinician: Using the components of a brief intervention from SBIRT role play how you would approach the conversation with the client about the risk for an alcohol-exposed pregnancy.
Take no more than 5 minutes and then switch roles and repeat the role play using the other client scenario again taking no more than 5 minutes.
Take 3 minutes to process with each other how it felt to use the brief intervention approach both from the clinician and client perspective.
Downloads
Alcohol-Use-Card-Guide ACOG.pdfRisky alcohol use guide
Brief Intervention Guidance.pdfBrief intervention guidance
one-key-question-overview.pdfOne Key Question
What Do I Say - Frequently asked questions about alcohol-exposed pregnancies.pdfWhat do I say?
6:. Case studies for brief interventions
Presentation
Presenter: Marilyn Pierce-Bulger, MN, FNP, CNM Length: 26 minutes
This webinar illustrates various examples of brief interventions including a case study and answers to common questions pregnant clients may have about alcohol use.
Access at www.npwh.org/courses/home/details/831. Registration may be necessary.
Learning objectives
Review client responses in sample screening scenarios.
Discuss possible provider responses to scenarios.
Suggested supplemental reading
Kelsey B, & Pierce-Bulger, M. Having the conversation about alcohol as a teratogen: Three women. Women's Healthcare. 2017:36-40.
Suggested skills demonstration videos
2-minute screening
An example of a 2-minute alcohol screening with a nurse practitioner and her client.
Length: 2:16 minutes
5-minute screening
An example of a 5-minute alcohol screening with a nurse practitioner and her client.
Length: 5:40 minutes
10-minute or less screening
An example of a 10-minute or less alcohol screening with a nurse practitioner and her client.
Length: 6:39 minutes
10-minute or less screening with a pregnant patient
An example of a 10-minute or less alcohol screening with a nurse practitioner and her client who is 10 weeks pregnant.
Length: 6:45 minutes
Suggested activities or assignments
Use role play activities (e.g., the AUDIT for alcohol screening, One Key Question, and CHOICES for intervention considerations) to practice opportunities for providing health interventions for women of reproductive age that address prevention of alcohol-exposed pregnancies.
Peer-to-Peer Motivational Interviewing Role Play – 15 minutes to set up and complete
Find a partner. Read both the scenarios and decide who will be the client and who will be the clinician for each one.
Scenario # 1: Client comes to the clinic to have her IUD removed because she wants to become pregnant. When you ask about alcohol use as part of your routine preconception counseling, she answers that she currently drinks a glass of wine with dinner once a week. She says she did this during her first pregnancy, her healthcare provider at that time said it was not a problem, and the baby was fine.
Scenario # 2: Client comes to the clinic for emergency contraception. She discontinued her oral contraceptives 3 months ago because she thought they were causing her to gain weight. She occasionally uses condoms. When asked about alcohol use, she states that she has 2 or 3 beers most Fridays when she and her co-workers go to Happy Hour. She also says she might have up to 5 beers at a party but not more than once a month.
Decide which of you will be the client first and which will be the clinician.
Clinician – Using the components of motivational interviewing (feedback on alcohol screening results, listening for change language, options for changing drinking pattern) role play how you would approach the conversation with the client about the risk for an alcohol-exposed pregnancy.
Client – Respond in a manner so that the clinician does hear change language and the client is able to develop options for changing your drinking pattern.
Take no more than 5 minutes and then switch roles and repeat the role play using the other client scenario again taking no more than 5 minutes.
Take 3 minutes to process with each other how it felt to use motivational interviewing both from the clinician and client perspective.
Downloads
ABCs of Binge Drinking american college of cardiology.pdfThe ABCs of binge drinking
Alcohol-Use-Card-Guide ACOG.pdfRisky alcohol use guide
(courtesy of ACOG)
(courtesy of ACOG)
Brief Intervention Guidance.pdfBrief intervention guidance
What Do I Say - Frequently asked questions about alcohol-exposed pregnancies.pdfWhat do I say?
7. Preventing stigma, stereotyping, and bias related to alcohol use in women
Presentation
Presenter: Kathleen Tavenner Mitchell, MHS, LCADC Length: 24 minutes
It is easy to assume a woman who has a child living with an FASD fits a certain profile. This webinar discusses reasons why women may drink alcohol during pregnancy and how nurses can play a compassionate role in preventing FASD.
Access at www.npwh.org/courses/home/details/833. Registration may be necessary.
Learning objective
Discuss the role of the nurse in preventing FASD by supporting women with substance use disorders.
Suggested supplemental reading
ACNM Ethics Committee. Code of ethics with explanatory statements. Silver Spring, MD: American College of Nurse-Midwives; 2015.
American College of Obstetricians and Gynecologists. Alcohol abuse and other substance use disorders: Ethical issues in obstetric and gynecologic practice. August 2015.
Keyes KM, Hatzenbuehler ML, McLaughlin KA, et al. Stigma and treatment for alcohol disorders in the United States. American Journal of Epidemiology. 2010;172(12):1364-1372.
Seiler NK. Alcohol and pregnancy: CDC's health advice and legal rights of pregnant women. Public Health Reports. 2016;131(4):623-627.
Suggested activities or assignments
Stigma can be perpetuated due to cultural factors and inadequate information. Using CDC’s feature on FASD at www.cdc.gov/ncbddd/fasd/FASD-Awareness.html, discuss how our own assumptions potentially impact our methods to address difficult topics, like alcohol use and pregnancy, in clinical care. How has universal screening reduced perceived stigma and bias for other health issues (e.g., malnutrition, domestic violence, depression)?
Small group changing stigmatizing language activity
Gather in small groups of 3 to 4 students. Choose one of the following statements.
Statement # 1: FASDs are caused when a mother drinks alcohol during pregnancy.
Statement # 2: FASDs are completely preventable if a developing baby is not exposed to alcohol before birth.
Statement # 3: Many women are drinking alcohol and not using adequate contraception. This may put them at risk for an alcohol-exposed pregnancy.
Discuss ways in which the statement might be stigmatizing. Alter the statement in a way that you believe makes it less stigmatizing.
As a group present to the entire class the original statement, in what ways you thought it might be stigmatizing and how you changed the statement.
