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VERNA L. ROSE

AAP Issues Policy Statement on Parental Discipline of Children

A policy statement from the American Academy of Pediatrics (AAP) addresses how physicians should counsel parents on the use of discipline for their children, including the use of positive reinforcement and the potential negative effects of corporal punishment. "Guidelines for Effective Discipline" covers the developmental approach to discipline, strategies for effective discipline, punishment and the physician's role in encouraging parents to develop methods other than spanking in response to undesired behavior. Lists of specific physician activities and supplementary information are also included. The statement appears in the April 1998 issue of Pediatrics.

According to the AAP, an effective discipline strategy has three essential components:

• A positive, supportive, loving relationship between the parent or parents and child.
• Use of positive reinforcement strategies to increase desired behaviors.
• Removing reinforcement or applying punishment to reduce or eliminate undesired behaviors.

All three components must be functioning well for discipline to be successful, according to the policy statement. They must also occur in the context of a relationship in which children feel secure. The AAP stresses that children learn best from people they care enough to want to emulate and please, and who are good role models. The AAP strongly discourages the use of corporal punishment, because it has negative consequences and is no more effective than other approaches for dealing with undesired behavior in children.

The AAP recommends that physicians counsel parents to develop alternatives to spanking, such as "time outs" and removal of privileges. The statement includes a list of the negative consequences of spanking, including modeling aggressive behavior as a solution to conflict. The policy cites research showing that 90 percent of American families reported having used spanking as a means of discipline at some time, and that most adults were spanked when they were children.

Strategies for parents and other caregivers that help children learn positive behaviors include the following:

• Providing regular positive attention, sometimes called special time (opportunities to communicate positively with parents are important for children of all ages).
• Listening carefully to children and helping them learn to use words to express their feelings.
• Providing children with opportunities to make choices whenever appropriate options exist and then helping them learn to evaluate the potential consequences of their choice.
• Reinforcing emerging desirable behaviors with frequent praise and ignoring trivial misdeeds.
• Modeling orderly, predictable behavior, respectful communication and collaborative conflict resolution strategies.

The policy statement acknowledges that discussing discipline with parents can be difficult. Both the physician's beliefs about discipline and the parents' beliefs were formed in childhood under emotional circumstances. Also, some religious groups have positions on the issue. Some parents, because of the increasing recognition of child abuse in the home, may also be reluctant to talk about their own ways of discipline. The AAP recommends that physicians begin a discussion by making an observation about the child's behavior and asking about the child's behavior at home. A negative response by the parent may indicate that the extent of the problem should be determined.

The AAP recommends a number of specific physician activities when counseling families about discipline. These include the following:

• Be clear about what is acceptable discipline.
• Avoid displaying strong emotions during the visit.
• Work to understand the parents' justification of their current practices and address their reasoning when presenting alternatives (offer privacy from children during this discussion).
• Demonstrate interest and expertise in child development and behavior during general visits to develop credibility for future discussions about discipline.
• Look for examples of the parents' effective discipline approach; help them gain strength and generalize from those positive experiences to other situations. Suggest ways to modify the family's techniques to make them more effective and appropriate.
• Participate in public education and advocacy to change cultural attitudes about discipline.

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ACOG Releases A Report on Risk Factors, Causes and Management of Postpartum Hemorrhage

SHARON SCOTT MOREY

The Committee on Educational Bulletins of the American College of Obstetricians and Gynecologists (ACOG) has released a report on the management of postpartum hemorrhage (Educational Bulletin No. 243). The report discusses the causes and management of postpartum hemorrhage.

The following is a summary of the ACOG report. The report begins by noting three factors that should be considered with regard to postpartum hemorrhage. First, blood loss is often underestimated by as much as 30 to 50 percent. Second, the expansion in blood volume that occurs during pregnancy compensates for normal blood loss at delivery, but this expansion occurs to a lesser degree in patients with preeclampsia. These patients have greater blood loss at delivery than do normotensive patients. Third, postpartum hemorrhage is likely to occur in subsequent pregnancies.

Risk Factors and Causes of Postpartum Hemorrhage

According to the ACOG report, the most common causes of postpartum hemorrhage are uterine atony and lacerations of the vagina and cervix. Other causes of postpartum hemorrhage include retained placental fragments, lower genital tract lacerations, uterine rupture or inversion, placenta accreta and hereditary coagulopathy. Causes of late postpartum hemorrhage (from 24 hours to six weeks after delivery) include infection, placental site subinvolution, retained placental fragments and hereditary coagulopathy.

Risk factors for uterine atony include uterine overdistention secondary to hydramnios, multiple gestation, use of oxytocin, fetal macrosomia, high parity, rapid or prolonged labor, intra-amniotic infection and use of uterine-relaxing agents. Predisposing factors for placenta accreta, which occurs in one of 2,500 deliveries, are previous puerperal curettage, cesarean delivery, hysterotomy, placenta previa and high parity. According to the report, the risk of placenta accreta may be 25 percent or higher in the presence of placenta previa and one or more previous cesarean delivery scars.

The report states that uterine rupture occurs in approximately one of 2,000 deliveries. Previous uterine surgery, particularly deep myomectomy or transfundal cesarean delivery, is a significant risk factor for uterine rupture and postpartum hemorrhage. Other risk factors include obstructed labor, multiple gestations, abnormal fetal lie and high parity.

Risk factors for hemorrhage at the time of cesarean delivery include preeclampsia, disorders of active labor, a history of previous hemorrhage, obesity, use of general anesthesia and intra-amniotic infection.

Management of Postpartum Hemorrhage

Management plan for postpartum hemorrhage. The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

The algorithm to the rightsummarizes the management of postpartum hemorrhage. The report states that adequate intravascular access should be obtained in women who have significant risk factors for postpartum hemorrhage. In the event of hemorrhage, supplemental oxygen should be administered to enhance cellular oxygen delivery and an indwelling urinary catheter should be inserted to facilitate assessment of intravascular volume resuscitation by monitoring urine output. Initial laboratory evaluation includes a complete blood count with platelet concentration. Blood type with antibody screen should be performed if it was not previously obtained. Fibrinogen, fibrin split products, prothrombin time and partial thromboplastin time should be measured.

Uterine atony should be initially managed by bimanual uterine massage and compression. Intravenous oxytocin, 10 to 40 U intravenously by continuous infusion, should be administered. Other uterotonic agents include methylergonovine and prostaglandin derivatives (15-methyl prostaglandin F_2a). According to the report, prostaglandin derivatives are associated with success rates of 88 percent when used alone and 95 percent when used in combination with other oxytocic agents. Methylergonovine may be administered in a dosage of 0.2 mg intramuscularly every two to four hours. This agent is contraindicated in the presence of hypertensive disease states because of the severe hypertension that may develop secondary to vasoconstriction induced by the agent. The administration of 15-Methyl prostaglandin F_2a may be given in a dosage of 0.25 mg intramuscularly every 15 to 90 minutes (no more than eight doses). This prostaglandin agent may also be given by intramyometrial injection at cesarean delivery or transabdominally after vaginal delivery. Prostaglandin E₂ may cause vasodilatation and exacerbation of hypotension, therefore 15-Methyl prostaglandin F_2a is preferred.

Surgical intervention is undertaken for direct indications, such as uterine curettage for suspected retained placental tissue, or for hemostasis if medical therapy fails. Obstetric lacerations are repaired by placing the initial suture above the apex of the laceration to control retracted arteries. Uterine artery ligation may be performed at laparotomy. Hypogastric artery ligation may be performed to reduce the arterial pulse pressure to pelvic organs. According to the report, hypogastric artery ligation is technically difficult and is successful in fewer than one half of patients. This intervention is increasingly being replaced by other forms of management. The most common indications for emergency hysterectomy include uterine atony, placenta accreta, uterine rupture, extension of a low transverse uterine incision and leiomyomata.

For more information on ACOG educational bulletins and committee opinions, contact ACOG at 409 12th St., S.W., Washington, D.C. 20090-6920; telephone: 800-762-2264.

Copyright © 1998 by the American Academy of Family Physicians.
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