Academic practice plans have been detrimental to the practice of assisted reproductive technology

The clinical practice of assisted reproductive technology combines cutting-edge medical science and its nearly immediate application to clinical practice, thus epitomizing academic medical practice. However, assisted reproductive technology programs find it difficult to remain within the academic setting, owing to the lack of flexibility of academic practice plans.     

Nurturing the future of midwifery through mentoring

Mentoring has become a popular approach for providing support in developing knowledge and practice across a variety of disciplines. Midwives often provide mentoring for midwifery mentees and newly graduated midwives without formal recognition or predetermined outcomes. Little literature exists within midwifery practice outlining how its use may be of value. This paper presents literature around the topic of mentoring, discussing possible benefits and suggesting ways in which mentoring may be utilised within midwifery to promote personal and professional development. Finally, it presents some of the limited examples of mentoring emerging from the midwifery literature.     

Developing the clinical nurse specialist's role in fertility: do patients benefit?

This article discusses the published studies surrounding the role of the clinical nurse specialist and its effect on patient care. Evidence is presented to indicate that the extended role of the clinical nurse specialist provides a positive benefit when centred on patient need. Fertility nurses have responded to the rapid developments within the field and demonstrated that they can deliver a high level of practice within assisted reproduction clinics. This article focuses on some of the areas of extended fertility nursing practice.     

Developing the clinical nurse specialist's role in fertility: Do patients benefit?

This article discusses the published studies surrounding the role of the clinical nurse specialist and its effect on patient care. Evidence is presented to indicate that the extended role of the clinical nurse specialist provides a positive benefit when centred on patient need. Fertility nurses have responded to the rapid developments within the field and demonstrated that they can deliver a high level of practice within assisted reproduction clinics. This article focuses on some of the areas of extended fertility nursing practice.     

Expanding Access to Midwifery Care: Using One Practice's Success to Create Community Change

Starting in 1991, Marin's County Certified Nurse‐Midwife‐Physician Collaborative Practice has proven to be a successful model of care for underinsured women. Functioning within the same hospital as traditional physician‐led practices, the practice displayed excellent clinical outcomes and gained respect within the community. Twenty years later, the Marin obstetric community decided to restructure its programs to incorporate the care of underinsured and privately insured women into one system. The goal was to design a system that would be patient‐centered, financially and professionally sustainable, and accessible to all women and would provide evidence‐based care with excellent outcomes. The community agreed, based on its own experience and on current literature, that continuing and expanding the midwife‐led model of care was a way to achieve these goals. Here we describe the history, practice, and outcomes of Marin's county practice and the factors that contributed to extending the availability of midwifery care to privately insured women.     

Litigation and defensive clinical practice: quantifying the problem

OBJECTIVE: To assess the evidence for claims about a rise in defensive clinical practice, particularly within maternity care; to describe an attempt to quantify the extent of defensive practice; and to identify areas for further research. DESIGN: Review of existing literature and a large scale postal survey. PARTICIPANTS: Over 2000 midwives and obstetricians, mostly based in Scotland. FINDINGS: Several claims have been made about the incidence of litigation, and its apparent effects on clinical practice. These effects, referred to as defensive practice, include both risk avoidance and risk-reduction strategies. Fears about recruitment to and retention within high-risk specialties have been expressed, especially in the USA. A majority of those midwives and obstetricians surveyed believed that litigation has caused a rise in defensiveness, and there was some agreement between the two groups about what constitutes defensive practice. However, there were discrepancies between the examples of defensive practice given by practitioners and what they admitted their own response to be. CONCLUSIONS: Defensiveness is believed to be fairly commonplace, but because of difficulties in defining and quantifying the concept of defensiveness it is unclear what the exact implications for clinical practice may be. Further research is required to establish this.     

ACOG Committee Opinion No. 408: Professional liability and gynecology-only practice

Fellows of the American College of Obstetricians and Gynecologists may choose to limit the scope of their practices to gynecology. The College considers early pregnancy care (often up to 12-14 weeks of gestation) to be within the scope of gynecology and gynecologic practice. Liability insurers who provide coverage for "gynecology-only" practices should provide coverage for clinical practice activities that involve the management of early pregnancy and its complications.     

COVID-19 in a community hospital

The rapid spread of COVID-19 across the globe quickly and drastically changed the way we practice medicine. In order to respond to its effects, careful planning and implementation of new guidelines and protocols was crucial to ensure the safety of both patients and staff. Given the limitations of space, staff, and resources in the community hospitals, a centralized command center, robust lines of communication within the department and between departments, and contingency and surge planning in this setting were critical. This chapter focuses on the unique challenges of practicing within a Level II hospital during a global pandemic.     

Introducing herbal medicine into conventional health care settings.

Herbal therapy is one of several holistic therapies gaining recognition within the health care community in the United States. As a discipline, herbal medicine is in its infancy regarding educational standards for credentialling, standardization, and regulation of products and clinical applications within this health care system. This article discusses professional considerations for midwives who are interested in integrating herbal healing into their clinical practices, and offers examples of how to incorporate herbal medicine into midwifery care. Resources for practitioners including books, newsletters, journals, courses, computer sites, and databases are presented. The author offers guidance for creating an herbal practice manual for the midwifery office as well as the hospital setting and for documenting herbal healing in the medical record. Collegial support, barriers to practice, liability, and insurance issues are discussed. A clinical applications section includes specific herbal formulas for preconception health, pregnancy-induced hypertension, gestational diabetes, and postdates pregnancy.     

Episiotomy Rates Around the World: An Update

ABSTRACT: Episiotomy, the unkindest cut of all, persists despite clinical practice guidelines recommending its restrictive use. The purpose of this paper was to compile international statistics on the use of this practice and examine whether current guidance on the restrictive use of episiotomy was being followed. Methods: We searched government websites and the Internet, contacted colleagues for references, and checked the references of retrieved citations. Results: Statistics from around the world revealed overall high rates of episiotomy with a decreasing trend in some countries. Considerable variation occurs in the use of the operation by country, within countries, and even within the same professional provider group. Conclusions: Greater efforts are needed than currently in place to reduce the episiotomy rate, particularly in the developing world.     

INTRODUCING HERBAL MEDICINE INTO CONVENTIONAL HEALTH CARE SETTINGS

Herbal therapy is one of several holistic therapies gaining recognition within the health care community in the United States. As a discipline, herbal medicine is in its infancy regarding educational standards for credentialling, standardization, and regulation of products and clinical applications within this health care system. This article discusses professional considerations for midwives who are interested in integrating herbal healing into their clinical practices, and offers examples of how to incorporate herbal medicine into midwifery care. Resources for practitioners including books, newsletters, journals, courses, computer sites, and databases are presented. The author offers guidance for creating an herbal practice manual for the midwifery office as well as the hospital setting and for documenting herbal healing in the medical record. Collegial support, barriers to practice, liability, and insurance issues are discussed. A clinical applications section includes specific herbal formulas for preconception health, pregnancy-induced hypertension, gestational diabetes, and postdates pregnancy.     

Acupuncture and in vitro fertilization: Critique of the evidence and application to clinical practice

Women undergoing in vitro fertilization (IVF) commonly use adjunctive therapies to improve IVF outcomes and reduce stress, anxiety and depression. Among these acupuncture is a popular choice. Despite 40 clinical trials and 9 systematic reviews investigating the efficacy of acupuncture for improving IVF outcomes, evidence-based guidelines are difficult to devise. The methodology used in the clinical trials does not closely resemble the use of acupuncture in real world acupuncture clinics, limiting the applicability of this research. Since many women undergoing IVF are currently using acupuncture there is a pressing need for a broader understanding of the use of acupuncture for female infertility. This paper offers a critical examination of the research on acupuncture and IVF and its limitations, details the differences between these studies and real world clinical practice, and discusses Chinese medicine theory for improving fertility and its possible scientific mechanisms within the context of clinical practice.     

Policy development

The implementation of certain therapies within clinical practice is dependent on nurses taking the initiative and expanding their scope of practice. In incorporating therapies within nursing practice it is hoped that a more holistic approach to care can be achieved.     

A summary of the workshop: Handling ART consent

Fertility nursing and its role extension has increasingly been referred to as ‘specialist’ or ‘advanced nursing practice’. Nevertheless, Government initiatives have prompted a review of Advanced Nursing Practice and the Nursing &; Midwifery Council (NMC) has taken steps to address the disparity of roles, job titles, training and competence of nurse practitioners, concluding that advanced nursing practice should be subject to revalidation in the same way as professional registration. Fertility nurses form an integral part of the multidisciplinary team. Yet no formal or nationally recognised framework or training pathway exists. In this paper, we present the findings of a recent online survey of training and educational needs of fertility nurses; its aim being to work toward developing a national training pathway. Our findings identify the relationship between fertility nurse competencies, advanced nursing practice and medical sub-specialist training, at the same time, highlighting the difference in accessibility, funding and levels of training, as well as assessment and expertise within clinical practice. We conclude that it is essential to protect role extension through regonised Higher Educational Institution (HEI) accreditation, by appropriate, role-focussed training. Notwithstanding a national review, the diverse list of job titles also needs to be addressed adequately to encompass and respect role extension.     

Working with Alice: a reflection

Reflective practice has become established within educational programmes and in clinical supervision. Yet what does it mean to be a reflective practitioner? This paper seeks to give some meaning to this concept by drawing on a story I wrote in my reflective journal one evening. My reflection on this event draws out key issues of practice and reflection that enable me to gain insight and apply to future practice within a reflexive learning spiral.     

Toward developing a training pathway for fertility nurses: report of the 2010 training and educational survey

Fertility nursing and its role extension has increasingly been referred to as 'specialist' or 'advanced nursing practice'. Nevertheless, Government initiatives have prompted a review of 'Advanced Nursing Practice' and the Nursing & Midwifery Council (NMC) has taken steps to address the disparity of roles, job titles, training and competence of nurse practitioners, concluding that advanced nursing practice should be subject to revalidation in the same way as professional registration. Fertility nurses form an integral part of the multidisciplinary team. Yet no formal or nationally recognised framework or training pathway exists. In this paper, we present the findings of a recent online survey of training and educational needs of fertility nurses; its aim being to work toward developing a national training pathway. Our findings identify the relationship between fertility nurse competencies, advanced nursing practice and medical sub-specialist training, at the same time, highlighting the difference in accessibility, funding and levels of training, as well as assessment and expertise within clinical practice. We conclude that it is essential to protect role extension through regonised Higher Educational Institution (HEI) accreditation, by appropriate, role-focussed training. Notwithstanding a national review, the diverse list of job titles also needs to be addressed adequately to encompass and respect role extension.     

Inter-cycle and inter-observer variability of the antral follicle count in routine clinical practice

Antral follicle count (AFC) is a reliable predictor of ovarian response to stimulation and its inter-cycle and inter-observer variability has been extensively studied on in vitro fertilization (IVF), mostly in highly selected populations within studies not originally designed for this purpose. In this retrospective cohort study, we assess the inter-cycle variation of AFC in a setting similar to that of the daily practice. We included only patients undergoing mild stimulation for intrauterine insemination (IUI). One hundred and forty-eight patients had two (62 patients, group A), three (49 patients, group B) or four (37 patients, group C) IUI cycles and AFC was measured on early follicular phase of each cycle by one of the members of the medical team within daily practice. Intra-class correlation coefficients were used to estimate variability. Inter-cycle variability rendered ICCs above 0.70 in all groups improving along with the number of cycles [Group A ICC 0.78 (95%CI 0.66–0.86), Group B ICC 0.87 (95%CI 0.80–0.92) and Group C ICC 0.91 (95%CI 0.85–0.95)]. Inter-observer variability showed a high degree of concordance with ICCs above 0.95. We provide the closest approximation to real inter-cycle and inter-observer AFC variability expected in routine clinical practice.     

Some current obstetric and gynaecological problems.

It has never been right to practise obstetrics and gynaecology in a purely mechanistic style. Medical practitioners have always discussed and argued, often driven by their patients, both the ethical framework and the individual circumstantial detail of practice within this specialty. This chapter starts by discussing the place of ethics and minimum core values for practice. Their integration into every doctor-patient relationship must be taught from the earliest training. It is not possible to catalogue every circumstance within the specialty where there are ethical problems to be addressed. Principles are outlined and many examples within the context of routine general specialty practice including aspects of pregnancy and fertility control are considered.     

Medical simulation for professional development--science and practice

From the earliest days of medical practice, when surgeons used cadavers to explore the possibilities of surgical intervention, simulation has been employed to advance the practice of health care. In the last 10 years, technological advances have allowed for a wider availability and greater realism of simulation, and this has encouraged a great expansion in its use. Simulation aims to create a virtuous cycle of professional development to improve patient outcomes. Although it seems eminently logical to believe that simulation will result in better outcomes, there is a need to test these new training interventions rigorously to be sure of their worth and to understand any limitations. The purpose of this BJOG supplement is to examine in depth several paradigms of medical simulation within maternity care and gynaecology, in different settings, looking at what can be achieved and how. In this opening review, we look at the potential use of medical simulation in broad terms and describe the types of evidence that can be employed to support its use.     

Midwifery and obstetrics: twenty years of collaborative academic practice

This review describes a collaborative educational practice model partnering midwifery and obstetrics within a department of obstetrics and gynecology. For more than 20 years, the authors' model has demonstrated sustainability and influence on medical education. The focus is on resident education in obstetrics, using midwifery faculty as teachers in the obstetric and obstetric triage settings. This noncompetitive and integrated educational practice model has achieved sustainability and success using midwives in a collaborative approach to medical education. The continuing collaboration and innovation within medical and resident education are important elements for the future of collaborative practice.