Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

Challenges to the improvement of obstetric care in maternity hospitals of a large Brazilian city: an exploratory qualitative approach on contextual issues

BACKGROUND

Maternal morbidity and mortality are still serious public health concerns in Brazil, and access to quality obstetric care is one critical point of this problem. Despite efforts, obstetric care quality problems and sub-optimal/poor outcomes persist. The study aimed to identify contextual elements that would potentially affect the implementation of an obstetric care quality improvement intervention.

METHODS

A qualitative study was conducted in three public maternity hospitals of a large Brazilian city, with high annual volume of births and buy-in from high-level managers. Individual interviews with doctors and nurses were conducted from July to October 2015. Semi-structured interviews sought to explore teamwork, coordination and communication, and leadership, being open to capture other contextual elements that could emerge. Interviews were recorded and transcribed, and the categories of analysis were identified and updated based on the constant comparative method.

RESULTS

Twenty-seven interviews were carried out. Extra-organizational context concerning the dependence of the maternity hospitals on primary care units, responsible for antenatal care, and on other healthcare organizations' services emerged from interviews, but the main findings of the study centered on intra-organizational context with potential to affect healthcare quality and actions for its improvement, including material resources, work organization design, teamwork, coordination and communication, professional responsibility vis-à-vis the patient, and leadership. A major issue was the divergence of physicians' and nurses' perspectives on care quality, which in turn negatively affected their capacity to work together.

CONCLUSION

Overall, the findings suggest that care on the maternity hospitals was fragmented and lacked continuity, putting at risk the quality. Redesigning work organization, promoting conditions for multi-professional teamwork, better communication and coordination, improving more systemic accountability/lines of authority, and investing in team members' technical competence, and fitness of organizational structures and processes are all imbricated actions that may contribute to obstetric care quality improvement.

Interdisciplinary Team Huddles for Fetal Heart Rate Tracing Review

To address an increase in unexpected poor outcomes in term neonates, our team developed a goal of high reliability and improved fetal safety in the culture of the Labor and Delivery nursing department. We implemented interdisciplinary reviews of fetal heart rate, along with a Category II fetal heart rate management algorithm and a fetal heart rate assessment rapid response alert to call for unscheduled reviews when needed. Enhanced communication between nurses and other clinicians supported an interdisciplinary approach to fetal safety, and we observed an improvement in health outcomes for term neonates. We share our experience with the intention of making our methods available to any labor and delivery unit team committed to safe, high-quality care and service excellence.

Introductory Engagement Within the Perinatal Nursing Relationship

In this article, the theme of introductory engagement is developed through the conversational interviews and participatory observations I carried out with perinatal nurses and birthing women in the context of a feminist phenomenological methodology. Positioned against the landscape of hierarchical health care practices embedded with power dynamics and disembodied practices, this research explored the ways in which perinatal nurses related to birthing women in the context of relational care. The focus of attention in this article is to describe the theme of introductory engagement by way of a storied phenomenological text.

Content Validity Testing of the Maternal Fetal Triage Index

OBJECTIVE

To describe the development and content validity testing of the Maternal Fetal Triage Index (MFTI), a standardized tool for obstetric triage.

DESIGN

Online survey.

PARTICIPANTS

Participants included 15 registered nurses, 15 certified nurse-midwives, and 15 physicians from across the United States who provided maternity care.

METHODS

A convenience sample of experienced clinicians was used as content validators for the MFTI. An item content validity index (I-CVI) was computed for the tool's items and a scale content validity index (S-CVI) was computed for the tool's scale based on the responses submitted via the online survey. Two rounds of content validation occurred.

RESULTS

In the first round of testing, a total of 12 of 61 items in the MFTI did not meet the I-CVI threshold of greater than 0.78 because of disagreement about clinical condition (75%) or priority level placement (25%). In the second round of testing, all but 3 of the 69 content items in the revised version of the MFTI had I-CVI thresholds greater than 0.78. These 3 items were related to vital sign values. The overall S-CVI score calculated for Round 2 only was 0.95, which was greater than the threshold of 0.90.

CONCLUSION

The results of the content validity testing of multidisciplinary validators suggest that the MFTI is a valid tool for use in obstetric triage and evaluation settings.

Striving to make births safer

IT IS eight years since nurse leader Chinomnso Ibe established the Traffina Foundation for Community Health (TFCH), a non-profit organisation that helps to reduce the high number of deaths from complications during pregnancy and delivery in Nigeria, her home country.

Perceptions about labor companionship at public teaching hospitals in three Arab countries

OBJECTIVE

To explore the perspectives of women, female relatives, and healthcare providers on labor companionship.

METHODS

In a qualitative study, data were collected from women giving birth, female family members, and healthcare staff via semi-structured interviews in three large public teaching hospitals in Beirut (Lebanon), Damascus (Syria), and Mansoura (Egypt) between May and December 2012. Focus groups were conducted with midwives, nurses, and medical residents. Data were assessed by thematic analysis.

RESULTS

A total of 69 women, 57 female relatives, and 28 obstetricians were interviewed, and two focus groups discussions occurred. Women reported that being alone during labor raises feelings of fear and anxiety. They reported appreciating professional support, but found comfort in the psychological support offered by family members during labor. Midwives and nurses pointed to structural factors related to the organization of care and to the marginalization of their role as barriers to implementing best practices. Obstetricians referred to the absence of prenatal education classes, and social norms as factors impeding the organization of labor support initiatives.

CONCLUSION

Implementing labor companionship can improve women's childbirth experiences and outcomes. Organizational structural barriers and non-supportive providers' attitudes need to be addressed to influence hospital practices.

Influenza infection control practices in labor and delivery units during the 2009 H1N1 influenza pandemic

OBJECTIVE

To assess the presence and usefulness of written policies and practices on infection control consistent with the Center for Disease Control and Prevention's (CDC) guidance in hospital labor and delivery (L&D) units during the 2009 H1N1 influenza pandemic.

SETTING

Online survey.

PARTICIPANTS

Of 11,845 eligible nurses, 2,641 (22%) participated. This analysis includes a subset of 1,866 nurses who worked exclusively in L&D units.

METHODS

A cross-sectional descriptive evaluation was sent to 12,612 members from the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) who reported working in labor, delivery, postpartum, or newborn care settings during the 2009 H1N1 influenza pandemic.

RESULTS

Respondents (73.8%) reported that CDC guidance was very useful for infection control in L&D settings during the pandemic. We assessed the presence of the following infection control written policies, consistent with CDC's guidance in hospital L&D units, during the 2009 H1N1 influenza pandemic and their rate of implementation most of the time: questioning women upon arrival about recent flu-like symptoms (89.4%, 89.9%), immediate initiation of antiviral medicines if flu suspected or confirmed (65.2%, 49%), isolating ill women from healthy women immediately (90.7%, 84.7%), ask ill women to wear masks during L&D (67%, 57.7%), immediately separating healthy newborns from ill mothers (50.9%, 42.4%), and bathing healthy infants when stable (58.4%, 56.9%). Reported written policies for five of the six practices increased during the pandemic. Five of six written policies remained above baseline after the pandemic.

CONCLUSIONS

Respondents considered CDC guidance very useful. The presence of written policies is important for the implementation of infection control practices by L&D nurses.

Tracking 'near misses' to keep newborns safe from falls

There is an increasing focus to keep newborns in the hospital safe from falls, as reports indicate that infant falls can occur in the immediate postpartum period. Previous reports have identified factors present at the time of newborn falls, yet there is little information on the prevalence of "near misses" or on risk factors present prior to the occurrence of falls. This article describes an innovative project to prevent newborn falls using information gathered about near misses. Most near misses occurred on the night shift, had the mother holding the baby and occurred an average of 52.6 hours after delivery. Collaboration among staff and patients is crucial to address risk factors present during near misses and to ultimately prevent newborn falls both in the hospital and at home.

[Gynecology and nursing practice in Ethiopia]

In Africa, many women suffer from the effects of a difficult childbirth. The obstetric fistula, a common condition, leads to suffering and stigmatisation. In this article, a nurse having carried out several humanitarian missions in Africa and the Middle East, shares with us the day-to-day work of Ethiopian nurses who have chosen to devote themselves to helping women affected by this disability.

Hard labor: the personal experiences of two obstetric nurses in Balad, Iraq

This article describes the experiences of two obstetric nurses as they deployed to the war zone in Iraq. Each discusses her role as a medical-surgical nurse and an emergency room nurse, respectively, and how she dealt with learning to practice in these areas. Each nurse came away from the experience with newfound confidence in her abilities and an appreciation for flexibility in practice. They also describe the challenges of deployment and being away from family, and how they coped with their feelings associated with nursing in a war zone and caring for injured service members and the indigenous population.

Perinatal safety: from concept to nursing practice

Communication and teamwork problems are leading causes of documented preventable adverse outcomes in perinatal care. An essential component of perinatal safety is the organizational culture in which clinicians work. Clinicians' individual and collective authority to question the plan of care and take action to change the direction of a clinical situation in the patient's best interest can be viewed as their "agency for safety." However, collective agency for safety and commitment to support nurses in their role of advocacy is missing in many perinatal care settings. This article draws from Organizational Accident Theory, High Reliability Theory, and Symbolic Interactionism to describe the nurse's role in maintaining safety during labor and birth in acute care settings and suggests actions for supporting the perinatal nurse at individual, group, and systems levels to achieve maximum safety in perinatal care.

Level of acceptance of different models of maternity care

To elicit nurses' opinions on five proposed models of maternity care in Ontario, to examine barriers to collaborative practice, and to identify factors that would encourage nurses to practise in the area of intrapartum care, a survey was mailed to a stratified random sample of nurses in Ontario (N = 750). Participants were asked whether they would consider practising in one or more of the five proposed models of maternity care. Almost half the participants endorsed the model of nurses' providing labour and delivery care to patients of family physicians and obstetricians. Almost one-third (28.7%) reported that they would consider working in an interprofessional maternity care clinic. There was minimal interest in working with midwives. Participants identified resistance to change (49.9%) and lack of communication (47.2%) as the two main barriers to collaborative practice. The majority of respondents (84.2%) ranked good medical and obstetrical backup as the key factor that would encourage them to provide intrapartum care. A respectful work environment and collaborative models of maternity care were also ranked highly.

In the margins of the mind: development of a projective research methodology for the study of nursing practice

This article presents an original research method derived from the Thematic Apperception Test used in clinical psychology to understand human motivation and action. The research method is derived from the theory of projection, which states that humans will perceive stimuli in terms of their own expectations and motives and will credit others with their own attitudes, beliefs, traits, and dispositions. Projective techniques are one of a handful of methods that provide access to this type of knowledge since it resides below the level of consciousness. Use of this type of method in nursing research may be fruitful because of its capacity to make apparent the complex interplay between a clinician's beliefs and the interpretation of meaning that motivates clinical action.

Obstetric nurses' attitudes and nursing care intentions regarding care of HIV-positive pregnant women

OBJECTIVE

To define attitudes toward pregnant women with HIV and how these attitudes correlate with and affect prejudice and nursing care intentions.

DESIGN

Cross-sectional descriptive correlational study of obstetric nurses.

SETTING

Eight hundred (800) mailed surveys in the United States (N = 350).

PARTICIPANTS

A random sample of nurses certified in inpatient obstetrics.

MAIN OUTCOME MEASURES

Background information tool, the Pregnant Women with HIV Attitude Scale, the Prejudice Interaction Scale in response to four vignettes, and the Marlowe-Crowne Social Desirability Scale-Form C.

RESULTS

Obstetric nurses had more positive Mothering-Choice attitudes than Sympathy-Rights attitudes (p= .000). Nurses who knew more than four people affected by HIV/AIDS had more positive attitudes (p<or= .05). Nurses with more positive attitudes were less prejudiced and more willing to care for pregnant women with HIV (p= .05). Nurses were significantly more prejudiced and less willing to care for women with than without HIV (p<or= .0001).

CONCLUSIONS

Nurses' clinical care may be influenced by their attitudes and prejudice toward pregnant women with HIV. Nursing education should include how prejudice can affect our clinical decision making and behaviors. Research is needed to explicate the effects on patient outcomes.

Implementing Newborn Mock Codes

This article describes the implementation of a newborn mock code program. Although the Neonatal Resuscitation Program (NRP) is one of the most widely used health education programs in the world and is required for most hospital providers who attend deliveries, research tells us that retention of NRP skills deteriorates rapidly after completion of the course. NRP requires coordination and cooperation among all providers; however, a lack of leadership and teamwork during resuscitation (often associated with a lack of confidence) has been noted. Implementation of newborn mock code scenarios can encourage teamwork, communication, skills building, and increased confidence levels of providers. Mock codes can help providers become strong team members and team leaders by helping them be better prepared for serious situations in the delivery room. Implementation of newborn mock codes can be effectively accomplished with appropriate planning and consideration for adult learning behaviors.

Nurses' attitudes toward provision of care and related health outcomes

BACKGROUND

Supportive care during childbirth is as old as humankind and has been a cornerstone of intrapartum practice for decades. Researchers have postulated that supportive care during labor leads to positive outcomes by enhancing normal labor physiology and the mother's childbirth experience. Questions, however, have risen about the ability of intrapartum nurses to provide effective supportive care within today's medicalized hospital birth environment.

OBJECTIVES

The aims of this study were to examine the contribution of attitudinal, normative, and control influences on intrapartum nurses' intentions to provide professional labor support (PLS) to parturient women and to assess if behavioral intent could predict the outcome of length of labor.

METHODS

A retrospective exploratory study was used to survey 39 registered nurses and 419 nurse-patient dyads to understand the relationship between predictor variables, behavioral intention, and health outcomes. Multiple regression analysis was used for statistical analysis.

RESULTS

The Theory of Planned Behavior (TPB) explained 70% of the variance in intrapartum nurses' intentions to provide PLS to their patients. Behavioral intent (beta = -.08, rho =.677) had no statistically significant impact on a patient's length of labor.

DISCUSSION

Both attitude and social pressures had a significant impact on the intention to perform PLS, and results show the relative importance of these variables in understanding the nurse's intention to provide support. Although behavioral intent had no significant influence on behavior, as measured by the patient's length of labor, clinical significance needs to be addressed. The regression correlation suggested that as the behavioral intent scores increased, length of labor decreased in the nurse's parturient population. Further studies are required to determine if the TPB can predict health outcomes through nurses' intentions to provide care.

Intervening to promote early initiation of breastfeeding in the LDR

PURPOSE

To evaluate the effectiveness of an interventional protocol for the early initiation of breastfeeding that would remove barriers in the labor, delivery, recovery (LDR) unit.

STUDY DESIGN AND METHODS

Descriptive design using 100 postpartum mothers who were interviewed before discharge at a large university hospital in the south-central United States. Descriptive statistics were used for analysis.

RESULTS

The protocol was effective for initiating breastfeeding, and breastfeeding increased from 53% to 66%.

CLINICAL IMPLICATIONS

When barriers to breastfeeding are reduced in the LDR setting, women will breastfeed. It is possible that reducing hospital barriers to breastfeeding in the LDR can also set the stage for sustained breastfeeding during hospitalization and for less supplementation with formula.

First assisting in obstetrics: a primer for women's healthcare professionals

As the cesarean rate rises nationwide, many maternity nurses, certified nurse-midwives, certified midwives, and other women's health nursing professionals are expanding their scope of practice to include first assisting with cesarean delivery. Becoming qualified to assist with cesarean section requires evaluation of facility, state, regulatory, and professional standards related to first assistants. First assisting education programs offer didactic education and clinical experience designed to ensure that surgical assistants are competent. Surgical first assistants for cesarean section are expected to be knowledgeable regarding the procedure, the relevant surgical anatomy, potential complications, and options for treatment. Acquiring clinical skills requires significant intraoperative experience under the tutelage of a knowledgeable mentor. In this article, the cesarean section procedure and the role and expectations of the surgical first assistant are described to provide the women's health nursing professional with the information needed to determine whether to include surgical first assisting with cesarean section as part of their professional practice.

Development of the Optimality Index as a New Approach to Evaluating Outcomes of Maternity Care

Evaluating perinatal outcomes within a framework of normalcy is a new focus of measurement. As maternal and child health clinicians and researchers look to evaluate care practices that are both of high quality and cost-effective, it is important to have measurement tools that assess differences among all women giving birth. The Optimality Index-US shifts the focus from rare adverse events to evidence-based optimal events. This article describes the continuing development of the index and discusses clinical implications for obstetric nurse clinicians.

A Concept Analysis of Optimality in Perinatal Health

This analysis was conducted to describe the concept of optimality and its appropriateness for perinatal health care. The concept was identified in 24 scientific disciplines. Across all disciplines, the universal definition of optimality is the robust, efficient, and cost-effective achievement of best possible outcomes within a rule-governed framework. Optimality, specifically defined for perinatal health care, is the maximal perinatal outcome with minimal intervention placed against the context of the woman's social, medical, and obstetric history.

How to Implement Complementary Therapies for Laboring Women

Complementary therapies have been a part of nursing practice for centuries and are supported today as a part of nursing practice by many state boards of nursing. Some of these modalities can be used by nurses as a part of their comprehensive plan of labor support for women during the childbirth experience. This article describes five complementary therapies (aromatherapy, massage, use of birth balls, music therapy, and hydrotherapy), and how one large Midwestern hospital system implemented an educational program for nurses that helped them integrate complementary therapies into their nursing care for laboring women.

Nursing implications of the 2006 NIH State of the Science Conference Statement: Cesarean Delivery on Maternal Request

Will the nation's higher rate of cesarean deliveries (CDs) (over 29%) lead to increased health risks for mothers and their babies? In March 2006, a National Institutes of Health State of the Science Conference was convened to assess available research on the topic. The focus was to identify outcomes from research studies addressing "cesarean delivery on maternal request" (CDMR), defined as CD without a medical indication for either the mother or the fetus. This conference concluded that it is currently unknown whether CDMR is really a trend in the United States, or whether the emergence of this phenomenon is associated with any specific benefits and harms to mothers and babies. More research is needed to determine if a trend exists. On the basis of systematic review of studies, no "strong quality-evidence" was found comparing CD and normal vaginal delivery outcomes. Future research was recommended to develop studies for this purpose in areas such as placental abnormalities (placenta previa and accreta) and various neonatal outcomes. Research on "modifiable" factors during labor and delivery which might decrease maternal and neonatal complications, including the risk for future pelvic floor disorders, was also recommended in the 2006 Conference Statement.

A Nurse’s Journey to Treat Obstetric Fistulae in Niger

Obstetric fistula is a devastating condition that results from prolonged or unassisted labor. It produces debilitating physical and emotional consequences caused by constant leaking of urine and/or feces. Because high-quality medical care is available throughout the developed world, unrepaired obstetric fistulae are virtually nonexistent in developed nations. However, the condition is rampant in many developing countries, including Niger, a nation in West Africa. This article explains what obstetric fistula is, why it is such a problem, and what nurses and other health care professionals can do to help improve the situation worldwide. It also tells the story of one nurse who went on a volunteer mission to treat obstetric fistulae in Niger, where she met a courtyard full of women she will never forget.

Nurse-physician communication during labor and birth: implications for patient safety

OBJECTIVE

To describe communication between nurses and physicians during labor within the context of the nurse-managed labor model in community hospitals and its relationship to teamwork and patient safety.

DESIGN

Multicenter qualitative study involving focus groups and in-depth interviews.

SETTING

Labor and birth units in 4 Midwestern community hospitals.

PARTICIPANTS

54 labor nurses and 38 obstetricians.

METHODS

Focus groups and in-depth interviews were conducted using open-ended questions. Data were analyzed using inductive coding methods to gain understanding from the perspective of those directly involved.

MAIN OUTCOME MEASURES

Description of interdisciplinary interactions during labor.

RESULTS

Nurses and physicians shared the common goal of a healthy mother and baby but did not always agree on methods to achieve that goal. Two clinical situations critical to patient safety (fetal assessment and oxytocin administration) were frequent areas of disagreement and sources of mutual frustration, often leading to less than optimal teamwork. Minimal communication occurred when the mother and fetus are doing well, and this seemed to be purposeful and considered normal. Physicians and nurses had distinct opinions concerning desirable traits of members of the other discipline.

CONCLUSIONS

Interdisciplinary communication and teamwork could be improved to promote a safer care environment during labor and birth.

Policies and Practices for Maternal Support Options during Childbirth and Breastfeeding Initiation After Cesarean in Southeastern Hospitals

OBJECTIVE

To describe policies, practices, and associated rationales of hospital obstetric units regarding mothers' support person options during childbirth and to explore practices concerning support of breastfeeding initiation after cesarean delivery.

DESIGN

Descriptive telephone survey.

SETTING

Hospitals in the southeastern region of the United States.

PARTICIPANTS

Convenience sample of 154 obstetric nurse manager and nurse representatives employed by the participating hospitals.

MAIN OUTCOME MEASURES

Types of policies regarding mothers' support person options during childbirth and immediate postpartum stage, initiation of breastfeeding after cesarean birth, and attitudes about policies.

RESULTS

All hospitals allowed two or more support persons during vaginal births, 89% permitted only one support person during nonemergent cesareans, and 58.0% of the nurse representatives believed that mothers should be allowed a second support person. Less than one third (31.2%) of the hospitals considered a mother's request to breastfeed in the operating room, and most (78.6%) allowed mothers to breastfeed in the recovery room.

CONCLUSIONS

Overall, maternal support policies, practices, and nurse representatives' attitudes were mother and family friendly, particularly related to vaginal births. Though breastfeeding initiation after cesarean birth was encouraging, support person options during nonemergent cesarean births and related rationales warrant further examination.

Spirituality at the beginning of life

AIM

The aim of this paper was to explore the issues surrounding the spirit of the unborn child.

BACKGROUND

Pregnancy and birth have been recognised to have a spiritual nature by women and health professionals caring for them. Midwives and nurses are expected to have a holistic approach to care. I suggest that for care to be truly holistic exploration is required of the spiritual nature of the unborn fetus.

METHODS

Historical, philosophical and religious views of the spirit of the fetus, are explored as well as those of women. Investigation was made of views of the timing of 'ensoulment'.

RESULTS

The review demonstrates the value women place on the sacredness of pregnancy and birth, and that the spiritual nature of the unborn should be recognised.

CONCLUSION

This paper shows that the views and values women have of pregnancy and birth and the powerful, spiritual relationship they have with the unborn, indicates that further discussion and research needs to be carried out in this area.

RELEVANCE TO CLINICAL PRACTICE

It is recommended that all who work with women who are pregnant should recognise the spiritual nature of the unborn when carrying out care.

Dimensions of professional labor support for intrapartum practice

PURPOSE

To define and describe the dimensions of Professional Labor Support (PLS).

DESIGN AND METHODS

A factor-analytic study was conducted with a random sample of 146 intrapartum nurses in Texas. Nurses' responses to the Labor Support Questionnaire (LSQ) were subjected to principal components analysis and descriptive analysis.

FINDINGS

A six-factor solution indicated the dimensions of PLS: Tangible Support, Advocacy, Emotional Support-Reassurance, Emotional Support-Creating Control, Security and Comfort, Emotional Support-Nurse Caring Behavior, and Informational Support.

CONCLUSIONS

Although the presence of four dimensions was theorized, six dimensions were found. The emotional support dimension was identified by nurses as being an important component of labor support as indicated by the identification of three separate emotional support dimensions.