Developing a Systematic Approach to Obstetric Emergencies

ObjectiveTo determine the effect of standardized education specific to maternal resuscitation on nurses’ confidence and competence during obstetric emergencies and to determine the cost savings associated with the program.DesignPre- and postintervention surveys designed to measure perceived confidence and competence in resuscitation before and after Advanced Cardiac Life Support (ACLS) certification in combination with obstetric drills.SettingThe project was conducted at a 12-bed labor and delivery, mother/baby unit in an acute care, community-based hospital in Northwest Arkansas.ParticipantsSixty-seven registered nurses (RNs) who were hospital employees with at least 6 months experience in labor and delivery or the neonatal intensive care unit completed focused education and training.Interventions/MeasurementsThe obstetric ACLS program targeted obstetric emergencies, cardiac arrest in the mother, and simulated drills. Obstetric emergencies included cardiac arrest, postpartum hemorrhage, STAT cesarean, uterine rupture, prolapsed umbilical cord, shoulder dystocia, operative vaginal delivery, and eclampsia.ResultsComparison of pre- and postassessments revealed improvements in perceived confidence and competence when managing obstetric emergencies. Nurse confidence increased by 35% and nurse competence increased by 32%. The 2-day educational program also realized significant cost savings. Overall costs for the educational program decreased from $94849 to $42974.ConclusionAn educationally sound program that included classroom time and focused drills led to increased perceived confidence and competence for nurses and cost savings related to employee education.     

Practice of Primary Elective Cesarean Upon Maternal Request in the Commonwealth of Virginia

ObjectivesTo evaluate the practice of on‐demand elective cesarean delivery in Virginia.DesignCross‐sectional.SettingHospital based.ParticipantsNurse managers or labor and delivery charge nurses of all 55 hospitals in Virginia that provide obstetric services.MethodsInterviews were conducted with participants to obtain quantitative and qualitative data.Results71.7% of hospitals reported that they would allow and have performed on‐demand cesarean delivery. The prevalence of this practice did not vary substantially according to hospital size and type or characteristics of providers of obstetric care. The only criterion that all hospitals mandated before allowing on‐demand cesarean delivery was that pregnancy must have completed 39 weeks of gestation.ConclusionsThe perception of labor and delivery managers in Virginia is that on‐demand elective cesarean delivery is a patient‐driven practice that does not appear to be influenced by hospital characteristics.     

Effects of combined spinal–epidural analgesia on first stage of labor: a cohort study

Background: Neuraxial anesthesia is considered as the gold standard in the control labor of pain. Its variants are epidural analgesia and combined spinal–epidural analgesia. Few studies, as yet, have investigated the duration of labor as a primary outcome. Some authors have suggested that combined spinal–epidural analgesia may reduce labor duration but at the moment the benefit of shortening labor is uncertain. The main aim of this study was to compare combined spinal–epidural with epidural analgesia in terms of their effect on duration of stage I labor, maternal, and neonatal outcomes.

Methods: A prospective cohort study was conducted. Parturients who requested analgesia at cervical dilatation <6?cm were included. Analgesia was either epidural with low concentration levobupivacaine or combined spinal epidural with subarachnoid sufentanil. The primary outcome was the length of stage I labor. Onset and quality of analgesia, mode of delivery, effects on uterine activity and use of oxytocin, fetal heart rate abnormalities and uterine hyperkinesia, maternal, and neonatal complications were also considered.

Results: We enrolled 400 patients: 176 in the combined spinal–epidural group and 224 in the epidural group. Patients in the two treatment groups were similar with regard to demographic characteristics, parity, and incidence of obstetric comorbidities, labor induction, oxytocin infusion, Bishop score, and Visual Analogue Score (VAS) at analgesia request. Duration of stage I labor did not differ, at 195 (120–300) minutes for both the groups (p?=?.7). Combined spinal–epidural was associated with less reduction in uterine contractility after initial administration: 15.34 versus 39.73%, (p?p?=?.002). Onset of analgesia was quicker for combined spinal–epidural analgesia: 31 versus 20%, with VAS <4 after 5?minutes, (p?Conclusions: Combined spinal–epidural with subarachnoid sufentanil may not reduce the duration of stage I labor, but in our study it appeared to affect uterine contractility less. It also had a more rapid onset and was more effective, without any concomitant increase in maternal or neonatal complications.     

The impact of obstetric gel on the second stage of labor and perineal integrity: a randomized controlled trial

Objective: Dianatal® is a bioadhesive gliding film which reduces the opposing force to vaginal childbirth. We aimed to investigate the safety, applicability, and impact of Dianatal® obstetric gel on second stage of labor and perineal integrity.

Methods: Low-risk singleton pregnancies at term were prospectively enrolled. Eligible women were randomly assigned to either labor management without using obstetric gel, or labor management using intermittent application of obstetric gel into the birth canal during vaginal examinations, starting at active phase of labor (≥4?cm dilation). The primary measured outcome was the length of second stage of labor.

Results: Overall, 200 cases were analyzed. Demographic, obstetrical, and labor characteristics were similar between the groups. Neither adverse events nor maternal or neonatal side effects were observed. The mean lengths of the active and second stages of labor were comparable between the obstetric gel-treated and the control groups (157 versus 219 min and 48 versus 56 min, respectively). None of the women had grade III/IV perineal tears. Maternal and neonatal outcomes were not negatively influenced by using obstetric gel. No difference was found after sub-group analysis for spontaneous vaginal delivery.

Conclusion: Dianatal® obstetric gel is safe in terms of maternal or neonatal use. Albeit a trend toward shorter labor stages using Dianatal® obstetric gel, no significant differences were noted among the groups. In order to further investigate the influence of the obstetric gel on labor stage interval, perineal integrity and maternal and neonatal outcomes, larger randomized clinical trials are needed to be carried out.     

PRONTO training for obstetric and neonatal emergencies in Mexico

ObjectiveTo evaluate the acceptability, feasibility, rating, and potential impact of PRONTO, a low-tech and high-fidelity simulation-based training for obstetric and neonatal emergencies and teamwork using the PartoPants low-cost birth simulator.MethodsA pilot project was conducted from September 21, 2009, to April 9, 2010, to train interprofessional teams from 5 community hospitals in the states of Mexico and Chiapas. Module I (teamwork, neonatal resuscitation, and obstetric hemorrhage) was followed 3 months later by module II (dystocia and pre-eclampsia/eclampsia) and an evaluation. Four elements were assessed: acceptability; feasibility and rating; institutional goal achievement; teamwork improvement; and knowledge and self-efficacy.ResultsThe program was rated highly both by trainees and by non-trainees who completed a survey and interview. Hospital goals identified by participants in the module I strategic-planning sessions were achieved for 65% of goals in 3 months. Teamwork, knowledge, and self-efficacy scores improved.ConclusionPRONTO brings simulation training to low-resource settings and can empower interprofessional teams to respond more effectively within their institutional limitations to emergencies involving women and newborns. Further study is warranted to evaluate the potential impact of the program on obstetric and neonatal outcome.     

Integrative Review of Parents’ Perspectives of the Nursing Role in Neonatal Family-Centered Care

ObjectivesTo identify the perceptions of mothers and fathers of newborns admitted to NICUs regarding the role of neonatal nurses in the provision of family-centered care and how neonatal nurses were able to interpret and meet parents’ needs.Data SourcesWe conducted literature searches in the CINAHL, MEDLINE, Embase, PsycINFO, Dissertations and Theses Global, and Maternity and Infant Care databases.Study SelectionArticles on qualitative and quantitative studies were selected if they were published in English from 2009 to 2018; they were set in countries with similar health care resources in Australasia, Canada, Europe, Scandinavia, the United Kingdom, and the United States; and the data were collected from parents. We identified 31 studies for analysis.Data ExtractionWe used the thematic analysis method of Braun and Clarke to extract data elements that were grouped and coded into themes and subthemes.Data SynthesisThrough ongoing iterative analysis, we generated six themes from the 18 subthemes that in combination presented the experiences of parents in the context of family-centered care provided by neonatal nurses: Process of Becoming a Parent, Neonatal Nurses Supporting Parents, Infant Safety, Communication, Barriers to Parenting, and Parenting Inhibited by Neonatal Nurses.ConclusionThe six themes reflected the contribution made by neonatal nurses to family-centered care in the NICU. The parents’ perspectives of nurses were mostly positive, but some negative aspects attributed to nurses identified in earlier studies persisted.     

Midwife-led care unit for ‘low risk’ pregnant women in a Japanese hospital

Objectives.?To examine the obstetric outcomes of our ‘low risk’ pregnant women under the midwife-led delivery care compared with those under the obstetric shared care.

Methods.?A retrospective cohort study compared outcomes of labor under midwife ‘primary’ care with those under obstetric shared care. The factors examined were: maternal age, parity, gestational age at delivery, length of labor, augmentation of labor pains, delivery mode, episiotomy, perineal laceration, postpartum hemorrhage, neonatal birth weight, Apgar score, and umbilical artery pH. In this study, pregnant women were initially considered ‘low risk’ at admission when they had no history of medical, gynecological, or obstetric problems and no complications during the present pregnancy.

Results.?There were 1031 pregnant women initially considered ‘low risk’ at admission. At admission, 878 of them (85%) requested to give birth under midwife care; however 364 of these women (42%) were transferred to obstetric shared care during labor. The average length of labor under the midwife ‘primary’ care was significantly longer than that under the obstetric shared care. However, there were no significant differences in the rate of prolonged labor (≥24?h). There were no significant differences in other obstetric or neonatal outcomes between the two groups.

Conclusions.?There was no evidence indicating that midwife ‘primary’ care is unsafe for ‘low risk’ pregnant women. Therefore, midwifery care is recommended for ‘low risk’ pregnant women.     

Admission volume is associated with mortality of neonatal respiratory failure in emerging neonatal intensive care units

Objective: The aim of this survey was to explore the relationship between admission volume and mortality of neonates with hypoxemic respiratory failure (NRF) in emerging neonatal intensive care units (NICUs).

Methods: NRF from 55 NICUs were retrospectively included with death risk as the major outcome. Perinatal comorbidities, underlying disease severity, respiratory support, facility utilization, and economic burden in the early postnatal period were compared among five NICU admission volume categories defined by NRF incidence, with score for neonatal acute physiology perinatal extension II (SNAPPE-II) also assessed as initial severity.

Results: Compared to NICUs with NRF?p?r?=?.282, p?p?Conclusions: Neonates in NICUs with smaller NRF admission volume and decreased magnitude of ventilator use had a higher risk of death as assessed by SNAPPE-II, which should be targeted in the quality improvement of newly established, resource-limited NICUs.     

Dilemma of increased obstetric risk in pregnancies following IVF-ET

Purpose : To determine the rates of pregnancy complications following in vitro fertilization in comparison with those in a matched control group. Methods : A total of 13,543 deliveries at the Department of Obstetrics and Gynecology, University of Szeged, between January 1, 1995 and February 28, 2002 were subjected to retrospective analysis. The 230 (1.7%) pregnancies following IVF-ET were evaluated and matched with spontaneous pregnancies concerning age, parity, gravidity, and previous obstetric outcome. Demographic and selected maternal characteristics, pregnancy and labor complications, and neonatal outcome were compared in the two groups. Results : The pregnancy complication rate was partly significantly higher among the singleton IVF-ET pregnancies. The obstetric risk was elevated, though not significantly concerning twin pregnancies. Conclusions : IVF-ET presents an additional obstetric risk. The neonatal outcome displays a significant difference only concerning an increased premature birth rate of singleton pregnancies. Triplet IVF-ET pregnancies involve a much higher risk of both pregnancy complications and neonatal outcome.     

The effects of labor on infant mortality among small-for-gestational-age infants in the USA

Objective: To determine whether the presence of labor affects infant mortality among small-for-gestational-age (SGA) infants. Methods: Data were derived from the United States national linked birth/infant death data sets for 1995–97. Singleton SGA live births in cephalic presentation delivered at 24–42 weeks' gestation were included. Mortality rates for SGA infants exposed and unexposed to labor were compared, and relative risks (RR) were derived using multivariable logistic regression models, after adjusting for potential confounding factors. Results: Of 986 405 SGA infants, 87.4% were exposed to labor. Infants exposed to labor at 24–31 weeks had greater risks of dying during the early neonatal period (RR 1.79-1.86). Decreased risks of late and postneonatal death were observed at all gestational ages in the presence of labor. Conclusions: Exposure to labor is associated with an increased risk of early neonatal death among SGA infants, especially at gestational ages below 32 weeks. Future randomized trials are warranted to determine the optimal obstetric management of these high-risk infants.     

Childbirth and the Development of Acute Trauma Symptoms: Incidence and Contributing Factors

Background: Little is known about the relationship between women's birthing experiences and the development of trauma symptoms. This study aimed to determine the incidence of acute trauma symptoms and posttraumatic stress disorder in women as a result of their labor and birth experiences, and to identify factors that contributed to the women's psychological distress. Method: Using a prospective, longitudinal design, women in their last trimester of pregnancy were recruited from four public hospital antenatal clinics. Telephone interviews with 499 participants were conducted at 4 to 6 weeks postpartum to explore the medical and midwifery management of the birth, perceptions of intrapartum care, and the presence of trauma symptoms. Results: One in three women (33%) identified a traumatic birthing event and reported the presence of at least three trauma symptoms. Twenty‐eight women (5.6%) met DSM‐IV criteria for acute posttraumatic stress disorder. Antenatal variables did not contribute to the development of acute or chronic trauma symptoms. The level of obstetric intervention experienced during childbirth (β= 0.351, p < 0.0001)and the perception of inadequate intrapartum care (β= 0.319, p < 0.0001) during labor were consistently associated with the development of acute trauma symptoms. Conclusions: Posttraumatic stress disorder after childbirth is a poorly recognized phenomenon. Women who experienced both a high level of obstetric intervention and dissatisfaction with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate. These findings should prompt a serious review of intrusive obstetric intervention during labor and delivery, and the care provided to birthing women.     

Effectiveness of an Obstetrics‐Based Advanced Cardiac Life Support Education Program

ObjectiveTo study the effectiveness of an obstetrics‐based advanced cardiac life support education (ACLS OB) program with pre‐ and postcourse maternal mock code drills and surveys evaluating satisfaction and self‐confidence in abilities of labor and delivery (L&D) nurses to perform ACLS algorithms.DesignQuasi‐experimental pretest/posttest study.SettingObstetric units in a community hospital system.ParticipantsLabor and delivery nurses (N = 96).MethodsNurses rotated through an ACLS OB course when their ACLS recertification was due. Two studies were done. Prior to the class, nurses participated in a maternal mock code drill during annual skills review, and performances were scored. One year later, nurses participated in maternal mock code drills. Results were compared with the previous year's scores. In the second study, pre‐ and postclass surveys were completed reflecting nurses’ satisfaction and self‐confidence with successfully completing elements of American Heart Association (AHA) algorithms following attendance at traditional ACLS classes versus ACLS OB.ResultsThe scores of nurses who completed the ACLS OB course were significantly greater overall when performing ACLS MegaCode algorithms (z = −6.08, p < .001) for 18 of 21 individual elements of the algorithm. Nurses reported statistically significant increases (p < .001) in all 13 elements of satisfaction and self‐confidence following completion of ACLS OB over traditional ACLS courses.ConclusionsEmphasizing changes in ACLS for obstetric patients during the precourse and using patient scenarios encountered in obstetric settings improved nurses’ performance in maternal MegaCode scenarios. The course also increased self‐satisfaction and self‐confidence of obstetric nurses in their ability to perform ACLS algorithms.     

Perspectives of Hospital‐Based Nurses on Breastfeeding Initiation Best Practices

ObjectiveTo assess the variation in breastfeeding knowledge and practices of registered nurses in hospital women and family‐care units and the informal and formal hospital policies related to the initiation and support of breastfeeding.DesignThis qualitative study employed a focus group approach to solicit perceptions of hospital‐based nurses regarding breastfeeding best practices.SettingEight state hospitals stratified by socioeconomic status (SES) and size served as settings to recruit participants for this study.ParticipantsForty female registered nurses from labor and delivery (n=9), postpartum (n=13), labor and delivery/recovery/postpartum care (LDRP) (n=12) and neonatal intensive care unit (NICU) (n=6) constituted eight focus groups.ResultsThe majority of nurses reported being knowledgeable of evidence‐based best practices related to breastfeeding initiation. However, in non‐Baby Friendly/Baby Friendly Intent (non‐BF/BFI) settings, nurses' knowledge often was not in accordance with current best practices in breastfeeding initiation, and reported hospital policies were not based upon evidence‐based practices. Barriers to best practices in breastfeeding initiation included hospital lactation policies (formal and informal), nurses' limited education in breastfeeding initiation best practices, high rates of surgical delivery, and lack of continuity of care with the transition of responsibility from one nurse to another from labor and delivery to transition care to postpartum care.ConclusionsA significant disparity between nurses' intention to support breastfeeding and their knowledge suggests a need for education based on the World Health Organization Baby Friendly standards for nurses at non‐BF/BFI hospitals. A significant barrier to supporting breastfeeding is lack of hospital policy and inappropriate or outdated policy.     

Obstetric and Neonatal Outcomes in People Who Acquired a Spinal Cord Injury During Pregnancy

ObjectiveThe objectives of this study were to determine the obstetric and neonatal outcomes of people who acquired spinal cord injuries (SCI) during pregnancy.MethodsThis is part of an international observational questionnaire examining pregnancy outcomes of people with SCI. The outcome measures included demographics, level of injury and American Spinal Injury Association scores, prenatal and postnatal complications, and neonatal outcomes.ResultsOf 780 responses, 14 (1.79%) participants reported acquiring an SCI while pregnant. 64.2% (9/14) of injuries were due to trauma. Of 14 pregnancies, 1 person miscarried, and 3 pregnancies were terminated. There were 11 live births. One participant had twins and 9 live births were singletons. Six participants delivered vaginally, 3 had a cesarean delivery and 1 was unreported. The preterm birth rate was 54.5% (6/11). Approximately 36% (4/11) of newborns were admitted to the neonatal intensive care unit. The average birth weight reported was 2409.7 g (456.3 g–3458.6 g). Forty percent (4/10) of participants reported experiencing postpartum blues or depression. Sixty percent (6/10) of participants breastfed for over 2 weeks.ConclusionsThis is the largest known cohort to date of persons acquiring SCI during pregnancy. The most common cause of SCI was a motor vehicle accident. Complications included preterm birth and neonatal intensive care unit admission. People who have an SCI during pregnancy are at risk for complications; however, positive pregnancy and neonatal outcomes are possible. Absolute small numbers of this event limit the ability to assess incidence of outcomes.     

Obstetric risk factors for poor neonatal adaptation at birth

Purpose: To identify obstetric risk factors of delivering a neonate with poor neonatal adaptation at birth.

Material and methods: Nested case–control study. Poor neonatal adaptation was defined for presence of at least: umbilical cord artery pH <7.10, base deficit ≥12?mmol/L, Apgar score at 1′ ≤5. Controls were selected from the same population and matched with cases. The association between clinical parameters and poor neonatal adaptation was analyzed by logistic regression.

Results: One hundred and thirty three women (2.1% of all live births) with a neonate presenting a poor neonatal adaptation were matched with 133 subsequent controls. Significant contributions for the prediction of poor neonatal adaptation were provided by maternal age ≥35 years (p?≤?.001, odds ratio (OR) 3.9 [95%CI: 2.3–6.8]), nulliparity (p?≤?.001, OR 3.3 [95%CI: 1.8–6]), complications during pregnancy (p?=?.032, OR 2.2 [95%CI: 1.1–4.4]), gestational age at delivery <37 weeks (p?=?.008, OR 5.2 [95%CI: 1.5–17.8]) and cardiotocography category II or III (p?≤?.001, OR 36.3 [95%CI: 16.5–80.1]). The receiver operative characteristic curve was 0.91 [95%CI: 0.87–0.95], and detection rates 82.7% and 89.5% at 10% and 20% of false positive rates, respectively.

Conclusions: Several obstetric risk factors before and during labor can identify a subgroup of newborns at higher risk of a poor neonatal adaptation at birth.