Monitoring the fetus in labor: evidence to support the methods

The evolution of professional obstetric nursing in the United States (1880's-present): Qualitative content analysis of specialty nursing textbooks

Background

Professional maternal-newborn/obstetric nursing in the United States emerged in the mid- 19th century coinciding with the increased medical management of childbirth. Before this mothers were attended by female family members, friends, neighbors and lay nurses or midwives.

Objective

To trace the evolution of professional maternal-newborn/obstetric nursing since its inception, identify factors which may have influenced this evolution, and consider how this knowledge can inform current issues and challenges in caring for childbearing families.

Methods

Qualitative content analysis, informed by historical research methods, was used to analyze selected content from a sample of maternal-newborn/obstetric nursing textbooks published from the 1880's to the present.

Findings

The last 150 years have been characterized by vast changes in medicine, technology and the healthcare system which have all influenced the evolution of professional maternal-newborn/obstetric nursing. Over the decades there has also been a significant change in the conceptualization of pregnancy/childbearing and our relative understanding of maternal and infant vulnerability. Findings revealed, however, that over time the primary focus of professional maternal-newborn/obstetric nursing care has consistently been: "protection, counseling/teaching and support" of childbearing families. In the U.S. maternal-newborn/obstetric nurses currently face many challenges including caring for an increasingly diverse patient population within a complex, technologically advanced healthcare system. This system is characterized by a high rate of cesarean section births, frequent intervention in vaginal births, disparities in access to care, and a high rate of preventable morbidity and mortality.

Conclusions

Since its origins the nursing profession has matured and nursing's allegience is now clearly to patients and society Today's nurses have the opportunity to play a key role in advocating for healthcare reform which would allow for less interference in the natural birth process, maximize patient outcomes, decrease inequities, and make comprehensive care for all mothers and infants a national priority.

Cerebroplacental ratio assessment in early labor in uncomplicated term pregnancy and prediction of adverse perinatal outcome: prospective multicenter study

OBJECTIVE

It has been suggested that the use of Doppler ultrasound in term pregnancies with normal-sized fetuses is able to identify those at high risk of subclinical placental function impairment. The objective of this study was to evaluate the relationship between cerebroplacental ratio (CPR) measured in early labor and perinatal and delivery outcomes in a cohort of uncomplicated singleton term pregnancies.

METHODS

This was a prospective multicenter observational study conducted at three tertiary centers between January 2016 and July 2017. Low-risk term pregnancies, defined by the absence of maternal morbidity or pregnancy complication, accompanied by normal ultrasound and clinical screening of fetal growth in the third trimester, with spontaneous onset of labor were included. Umbilical artery (UA) and fetal middle cerebral artery (MCA) Doppler was assessed on admission for early labor. All measurements were performed in between uterine contractions and according to international standards. CPR was computed by dividing MCA pulsatility index by UA pulsatility index and converted into multiples of the median (MoM) in order to adjust for gestational age. Doctors and midwives involved in the clinical management of the women were blinded to the results of the Doppler evaluation. Mode of delivery and perinatal outcome were compared between pregnancies with reduced CPR MoM, defined as CPR MoM within the lowest decile of the study population, and those with normal CPR MoM. Receiver-operating characteristics curve analysis was used to assess the predictive performance of CPR for obstetric intervention due to fetal distress and composite adverse perinatal outcome.

RESULTS

Overall, 562 women were included. The rate of obstetric intervention for suspected fetal distress in labor was more than three times higher among cases with reduced CPR MoM compared to those with normal CPR MoM (9/54 (16.7%) vs 28/508 (5.5%); P = 0.004). Furthermore, a significantly higher rate of composite adverse perinatal outcome was found in fetuses with CPR MoM < 10^th percentile compared to those with CPR MoM ≥ 10^th percentile (6/54 (11.1%) vs 19/508 (3.7%); P = 0.012). CPR had low sensitivity and low positive predictive value for prediction of obstetric intervention due to fetal distress (24.3% and 18.0%, respectively) and composite adverse perinatal outcome (24.0% and 11.1%, respectively).

CONCLUSIONS

Data on a wide cohort of low-risk term pregnancies in early labor showed that, while reduced CPR is associated with a higher risk of obstetric intervention due to fetal distress and composite adverse perinatal outcome, it is a poor predictor of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Midwives' perceptions on using a fetoscope and Doppler for fetal heart rate assessments during labor: a qualitative study in rural Tanzania

Background

The Doppler is thought to be more comfortable and effective compared to the fetoscope for assessing the fetal heart rate (FHR) during labor. However, in a rural Tanzanian hospital, midwives who had easy access to both devices mostly used fetoscope. This study explored midwives’ perception of factors influencing their preference for using either a Pinard fetoscope or a FreePlay wind-up Doppler for intermittent FHR monitoring.

Methods

Midwives who had worked for at least 6 months in the labor ward were recruited. Focus group discussion (FGD) was used to collect data. Five FGDs were conducted between December 2015 and February 2016. Qualitative content analysis was employed using NVivo 11.0.

Results

Three main themes emerged as factors perceived by midwives as influencing their preference; 1) Sufficient training and experience with using a device; Midwives had been using fetoscopes since their midwifery training, and they had vast experience using it. The Doppler was recently introduced in the maternity ward, and midwives had insufficient training in how to use it. 2) Ability of the device to produce reliable measurements; Using a fetoscope, one must listen for the heartbeat, count using a watch, and calculate, the Doppler provides both a display and sound of the FHR. Fetoscope measurements are prone to human errors, and Doppler measurements are prone to instrumental errors. 3) Convenience of use and comfort of a device; Fetoscopes do not need charging, and while it is possible to “personalize/hide” the measurements, and may be painful for mothers. Dopplers need charging and do not cause pain, but provide limited privacy.

Conclusion

Midwives’ preferences of FHR monitoring devices are influenced by the level of device training, experience with using a device, reliable measurements, and convenience and comfort during use. Fetoscopes and Dopplers should be equally available during midwifery training and in clinical practice.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1736-y) contains supplementary material, which is available to authorized users.

Admission Test and Pregnancy Outcome

BACKGROUND

The admission test (AT) has been carried out for many years, but there are still debates about the prognostic value of the test. Therefore, we aimed to examine the value of the AT in predicting the adverse outcome in neonates.

METHODS

In this cross-sectional study, 425 pregnant women with normal vaginal delivery were studied between2009 and 2014at Vali-e-Asr Hospital. Based on the results, the women were divided into 2groups of normal and abnormal ATs. All the patients were followed up until the birth of their baby, when the status of mother and neonate was determined. The main outcomes of the study were cesarean rate, neonatal intensive care unit (NICU) admission, fetus demise, neonatal acidosis, and Apgar score. The independent t-test, chi-square test, Fisher exact test, and logistic regression were used for statistical analysis. The data were analyzed using SPSS (version 17).

RESULTS

Of 425 pregnant women studied, 142 (33.4%) had abnormal ATs with a mean age of 29 (±4.5) years. Multivariate analysis showed that an abnormal AT was able to predict the incidence of cesarean section, intrauterine growth restriction, turned cord, and Apgar<7, but it could not predict neonatal death and hypoxia.

CONCLUSION

The AT was shown to be a useful screening test with risk factors such as oligohydramnios, bloody amniotic fluid, meconium amniotic fluid, intrauterine growth restriction, and turned cord. Additionally, the test was also able to predict NICU admission and the need for cesarean section, but it could not predict the occurrence of neonatal death.

Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being

BACKGROUND

The goal of fetal monitoring in labour is the early detection of a hypoxic baby. There are a variety of tools and methods available for intermittent auscultation (IA) of the fetal heart rate (FHR). Low- and middle-income countries usually have only access to a Pinard/Laënnec or the use of a hand-held Doppler device. Currently, there is no robust evidence to guide clinical practice on the most effective IA tool to use, timing intervals and length of listening to the fetal heart for women during established labour.

OBJECTIVES

To evaluate the effectiveness of different tools for IA of the fetal heart rate during labour including frequency and duration of auscultation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (19 September 2016), contacted experts and searched reference lists of retrieved articles.

SELECTION CRITERIA

All published and unpublished randomised controlled trials (RCTs) or cluster-RCTs comparing different tools and methods used for intermittent fetal auscultation during labour for fetal and maternal well-being. Quasi-RCTs, and cross-over designs were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

All review authors independently assessed eligibility, extracted data and assessed risk of bias for each trial. Data were checked for accuracy.

MAIN RESULTS

We included three studies (6241 women and 6241 babies), but only two studies are included in the meta-analyses (3242 women and 3242 babies). Both were judged as high risk for performance bias due to the inability to blind the participants and healthcare providers to the interventions. Evidence was graded as moderate to very low quality; the main reasons for downgrading were study design limitations and imprecision of effect estimates. Intermittent Electronic Fetal Monitoring (EFM) using Cardiotocography (CTG) with routine Pinard (one trial)There was no clear difference between groups in low Apgar scores at five minutes (reported as < six at five minutes after birth) (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.24 to 1.83, 633 babies, very low-quality evidence). There were no clear differences for perinatal mortality (RR 0.88, 95% CI 0.34 to 2.25; 633 infants, very low-quality evidence). Neonatal seizures were reduced in the EFM group (RR 0.05, 95% CI 0.00 to 0.89; 633 infants, very low-quality evidence). Other important infant outcomes were not reported: mortality or serious morbidity (composite outcome), cerebral palsy or neurosensory disability. For maternal outcomes, women allocated to intermittent electronic fetal monitoring (EFM) (CTG) had higher rates of caesarean section for fetal distress (RR 2.92, 95% CI 1.78 to 4.80, 633 women, moderate-quality evidence) compared with women allocated to routine Pinard. There was no clear difference between groups in instrumental vaginal births (RR 1.46, 95% CI 0.86 to 2.49, low-quality evidence). Other outcomes were not reported (maternal mortality, instrumental vaginal birth for fetal distress and or acidosis, analgesia in labour, mobility or restriction during labour, and postnatal depression). Doppler ultrasonography with routine Pinard (two trials)There was no clear difference between groups in Apgar scores < seven at five minutes after birth (reported as < six in one of the trials) (average RR 0.76, 95% CI 0.20 to 2.87; two trials, 2598 babies, I2 = 72%, very low-quality evidence); there was high heterogeneity for this outcome. There was no clear difference between groups for perinatal mortality (RR 0.69, 95% CI 0.09 to 5.40; 2597 infants, two studies, very low-quality evidence), or neonatal seizures (RR 0.05, 95% CI 0.00 to 0.91; 627 infants, one study, very low-quality evidence). Other important infant outcomes were not reported (cord blood acidosis, composite of mortality and serious morbidity, cerebral palsy, neurosensory disability). Only one study reported maternal outcomes. Women allocated to Doppler ultrasonography had higher rates of caesarean section for fetal distress compared with those allocated to routine Pinard (RR 2.71, 95% CI 1.64 to 4.48, 627 women, moderate-quality evidence). There was no clear difference in instrumental vaginal births between groups (RR 1.35, 95% CI 0.78 to 2.32, 627 women, low-quality evidence). Other maternal outcomes were not reported. Intensive Pinard versus routine Pinard (one trial)One trial compared intensive Pinard (a research midwife following the protocol in a one-to-one care situation) with routine Pinard (as per protocol but midwife may be caring for more than one woman in labour). There was no clear difference between groups in low Apgar score (reported as < six this trial) (RR 0.90, 95% CI 0.35 to 2.31, 625 babies, very low-quality evidence). There were also no clear differences identified for perinatal mortality (RR 0.56, 95% CI 0.19 to 1.67; 625 infants, very low-quality evidence), or neonatal seizures (RR 0.68, 95% CI 0.24 to 1.88, 625 infants, very low-quality evidence)). Other infant outcomes were not reported. For maternal outcomes, there were no clear differences between groups for caesarean section or instrumental delivery (RR 0.70, 95% CI 0.35 to 1.38, and RR 1.21, 95% CI 0.69 to 2.11, respectively, 625 women, both low-quality evidence)) Other outcomes were not reported.

AUTHORS' CONCLUSIONS

Using a hand-held (battery and wind-up) Doppler and intermittent CTG with an abdominal transducer without paper tracing for IA in labour was associated with an increase in caesarean sections due to fetal distress. There was no clear difference in neonatal outcomes (low Apgar scores at five minutes after birth, neonatal seizures or perinatal mortality). Long-term outcomes for the baby (including neurodevelopmental disability and cerebral palsy) were not reported. The quality of the evidence was assessed as moderate to very low and several important outcomes were not reported which means that uncertainty remains regarding the use of IA of FHR in labour.As intermittent CTG and Doppler were associated with higher rates of caesarean sections compared with routine Pinard monitoring, women, health practitioners and policy makers need to consider these results in the absence of evidence of short- and long-term benefits for the mother or baby.Large high-quality randomised trials, particularly in low-income settings, are needed. Trials should assess both short- and long-term health outcomes, comparing different monitoring tools and timing for IA.

Intelligent Structured Intermittent Auscultation (ISIA): evaluation of a decision-making framework for fetal heart monitoring of low-risk women

Background

Research-informed fetal monitoring guidelines recommend intermittent auscultation (IA) for fetal heart monitoring for low-risk women. However, the use of cardiotocography (CTG) continues to dominate many institutional maternity settings.

Methods

A mixed methods intervention study with before and after measurement was undertaken in one secondary level health service to facilitate the implementation of an initiative to encourage the use of IA. The intervention initiative was a decision-making framework called Intelligent Structured Intermittent Auscultation (ISIA) introduced through an education session.

Results

Following the intervention, medical records review revealed an increase in the use of IA during labour represented by a relative change of 12%, with improved documentation of clinical findings from assessments, and a significant reduction in the risk of receiving an admission CTG (RR 0.75, 95% CI, 0.60 – 0.95, p = 0.016).

Conclusion

The ISIA informed decision-making framework transformed the practice of IA and provided a mechanism for knowledge translation that enabled midwives to implement evidence-based fetal heart monitoring for low risk women.

The Evidence for Physiologic Management of the Active Phase of the First Stage of Labor

The active phase of first stage labor is generally defined as the period between 3 cm to 4 cm to complete cervical dilatation, in the presence of regular uterine contractions. Most women will experience this portion of labor within hospital obstetric units, where care commonly features restriction to bed, electronic fetal monitoring, early treatment of "slow" labors, and few pain management options beyond epidurals and narcotics. However, the available evidence on appropriate care for healthy childbearing women favors activity in labor, intermittent auscultation, patience from caregivers, and nonpharmacologic methods of pain relief. This article reviews the evidence for care practices that support physiologic labor. Modifying intrapartum care to reflect current evidence will improve women's health, and will require a multilevel approach and consistent midwifery demonstration of the model.

The International Confederation of Midwives' study of essential competencies of midwifery practice

OBJECTIVE

To delineate the knowledge, skills, and behaviours that would characterise the domain of competencies of the midwife who is educated according to the international definition of the profession.

DESIGN

Phase I: a qualitative Delphi study; Phase II: a descriptive survey research process.

PARTICIPANTS

A stratified random sample of member organisations of the International Confederation of Midwives (ICM) and regulatory representatives from these same countries.

FINDINGS

A list of basic (essential) and additional competencies for midwives who have been educated in keeping with the ICM/WHO/FIGO international definition of the midwife was developed through an interative Delphi process, and then affirmed, using a survey research method. The final list includes 214 individual task statements within six domains of midwifery practice.

IMPLICATIONS FOR PRACTICE

This list of competencies can serve as a basis for educational curriculum design, as a guideline for regulatory policy development, as a reference document for individual practitioners in an assessment of their initial and continued competency and by the ICM and its member associations as a resource for advocating for the role of midwifery within health-care systems world-wide.

A systematic approach for midwifery students: how to consider evidence-based research findings

The midwifery profession is increasingly applying the results of evidence-based research findings. Several researchers were asked if they would answer questions regarding the essential research skills necessary for midwives, the relevance of applying valid evidence to practice, and concerns regarding evidence-based practice overall. The objectives were to share expert researchers' responses that could be used by educators to help introductory midwifery students understand the importance of developing skills in assessing "the best evidence" and to stimulate interactive discussion in the classroom. Consideration of the expert opinions stimulated student thinking on the relation of evidence-based findings to practice in an exciting approach characterized by inquiry and debate, which got favorable responses and evaluations from the students.

Birth in the United States: an overview of trends past and present

The picture of birth in the United States today is complex and, as the data above indicates, difficult to describe in simplistic terms. Though many women today have come to believe that there are choices surrounding pregnancy and birth, the beliefs and practices of providers, insurers, and hospital administrators play a major role in either influencing those choices or dictating how they will be manifested. On one hand, technological advances have given women greater options with regard to the outcomes of pregnancy and birth. On the other hand, these very same technological advances place limits on the choices available to the individual. For example, increased efficiency in the placement and use of epidural anesthesia has made this a pain-control option for most of the childbearing women in the United States. The use of an epidural, however, puts limits on the choice of an institution at which to give birth and on the movements/activities of the woman during labor. Twentieth-century developments led to the almost complete demise of midwifery practice in the United States, thus taking birth away from the control of the individual woman and her close, matriarchal support system, and placing it in the hands of the patriarchal world of medicine and the institutions (i.e., hospitals) at which this approach to health care is practiced. Most births went from being normal, home-based events to becoming illness-oriented, hospital-based procedures. Just as some steps were being taken in the latter part of the twentieth century to return some of the control of birth back to pregnant women (e.g., childbirth education classes, the modern home-birth movement, increases in the number of midwifery-tended births), technological advances contributed to continued control by physicians and the hospitals of their practice (e.g., fetal monitoring, epidural anesthesia). Advances in technology have made birth possible for many individuals who otherwise would not have had the opportunity for this experience or a chance for a positive outcome (e.g., sufferers of infertility or the woman whose fetus has congenital yet repairable problems). But the widespread application of many of these advances to almost all pregnant and laboring women has raised questions as to just what is necessary for a healthy pregnancy, and are there limits to the role that technology should play in the course of what is viewed by many as a normal, nonmedical event. Just as the characters in 2001: A Space Odyssey recognized the incredible power of change that occurred in their lives as a result of the monolith being "born" into their world, so too do many women acknowledge the prodigious nature of giving birth in terms of the experience itself and the resulting effect on their lives [14]. But, as with the acknowledgment of Dr. Dave Bowman in 2001: A Space Odyssey that the technology of the fictitious future still could be wrong, thoughts of U.S. women giving birth today tend to be "in-between" a belief in the integrity of nature and a trust in the power of technology [14]. One can certainly conjecture that birth in the United States today, more than any other time in history, is at a crossroads, one in which the mostly natural, matriarchal community system of the sixteenth through nineteenth centuries is intersecting with the mostly technological, patriarchal system of the twentieth century. Will birth return to the home under the guidance of midwives, as was the case for most of America's past and as remains the case throughout much of the world? [32] Or will technology take birth to the other extreme, making it possible to eventually gestate outside the womb and rendering "delivery" a term not referring to passage through the birth canal, but to the dropping off a healthy term baby at the respective mother's doorstep? Certainly no one can predict what is to occur, but whatever that may be, hindsight will likely point to the start of the twenty-first century as the beginning of a new paradigm for birth in the United States. It should make for an interesting future.

Intrapartum care in the twenty-first century

Women will continue seeking obstetrical care from nurses, midwives, and physicians throughout the twenty-first century. In many areas of the country, they will be able to find a midwife who will assist them in having a very personal birth experience. The ACNM remains committed to producing more midwives. More midwives may mean that practitioners educated in normal pregnancy will attend the vast majority of normal births, freeing physician colleagues to best use their skills and expertise in caring for women with medical and obstetrical problems. As most midwives are likely to continue working in hospital settings, those settings will continue to change, offering women more of the comforts and amenities of home. Home birth and water birth may continue to be available with midwives in attendance, though the forces of economics and insurers may restrict the availability of these options for women. Women desiring care in a birth center may find it difficult to locate one within a reasonable distance. The in-hospital "birthing suite", with a midwife in attendance, will be the most likely setting for the vast majority of midwifery attended births. A collection of more evidence through research will stir debate amongst health care providers. Increased access to that information will bring consumers into the debate as well. In the twenty-first century, information will be a very powerful force of change in obstetrical health care. In recent years, legal liability and economics have strongly influenced obstetrical practice. Though this may continue to be true, the impact of more evidence on which to base practice, and the new access that women have to that information, will undoubtedly affect the way care is delivered. A central slogan of the ACNM is "Listen to Women". That will happen more than ever in the twenty-first century. There will be more midwives, more evidence to support midwifery care, and more women learning that birth can and should be a personal, healthy, and empowering experience. These women will seek midwives who practice wisely, blending science with art and intuition. They will learn that the childbirth wisdom that has been passed down through the ages, from woman to midwife to healer to nurse and to midwife, again, delivers the birth experience back to the mother and the healthy baby to the world [3,7].