Evidence‐Based Practice for Intrapartum Care: The Pearls of Midwifery

Care for women in labor in the United States is in a period of significant transition. Many intrapartum care practices that are standard policies in hospitals today were instituted in the 20th century without strong evidence for their effect on the laboring woman, labor progress, or newborn outcomes. Contemporary research has shown that many common practices, such as routine intravenous fluids, electronic fetal monitoring, and routine episiotomies, do more harm than good. In 2010, the American College of Nurse‐Midwives released a PowerPoint presentation titled Evidence‐Based Practice: Pearls of Midwifery. This presentation reviews 13 intrapartum‐care strategies that promote normal physiologic vaginal birth and are associated with a lower cesarean rate. They are also practices long associated with midwifery care. This article reviews the history of intrapartum practices that are now changing, the evidence that supports these changes, and the practical applications for the 13 Pearls of Midwifery.     

Improving Quality and Safety in Maternity Care: The Contribution of Midwife‐Led Care

This article draws on findings from a recent Cochrane systematic review of midwife‐led care and discusses its contribution to the safety and quality of women's care in the domains of safety, effectiveness, woman‐centeredness, and efficiency. According to the Cochrane review, women who received models of midwife‐led care were nearly eight times more likely to be attended at birth by a known midwife, were 21% less likely to experience fetal loss before 24 weeks' gestation, 19% less likely to have regional analgesia, 14% less likely to have instrumental birth, 18% less likely to have an episiotomy, and significantly more likely to have a spontaneous vaginal birth, initiate breastfeeding, and feel in control. In addition to normalizing and humanizing birth, the contribution of midwife‐led care to the quality and safety of health care is substantial. The implications are that policymakers who wish to improve the quality and safety of maternal and infant care, particularly around normalizing and humanizing birth, should consider midwife‐led models of care and how financing of midwife‐led services can support this. Suggestions for future research include exploring why fetal loss is reduced under 24 weeks' gestation in midwife‐led models of care, and ensuring that the effectiveness of midwife‐led models of care on mothers' and infants' health and well‐being are assessed in the longer postpartum period.     

Intrapartum Nursing Care: A Case Study of Supportive Interventions and Ethical Conflicts

Background: Studies have shown that one‐to‐one labor support is associated with a reduced rate of operative births, and with long‐term improvements of parenting and breastfeeding rates. Labor support by nurses may reduce the cesarean birth rate, but this has not been adequately studied. No one knows which labor support strategies nurses use, if they are effective, and how they work. Methods: This pilot study used the qualitative techniques of observation and an audiotaped interview with an expert intrapartum nurse to describe labor support techniques and strategies to enhance labor progress and prevent cesarean births. Results: The narrative revealed three major themes. The first theme, “the nurse's approaches to labor,” included three subcategories: “following the mother's body,”“hastening and controlling labor,” and “labor support techniques.” The second and third major themes, “ethical dilemmas: an unwilling partnership” and “nurse‐physician conflict,” were unanticipated. Labor support practices were limited by some physician practices. Inappropriate physician practice created ethical dilemmas for the nurse and impeded labor support interventions. Conclusions: Intrapartum nursing care reflected both a medical model of controlling and hastening birth, as well as a supportive, nurturing, and empowering model of practice that used independent clinical judgments and advocacy. Questionable medical care entangled the nurse in these practices and created moral dilemmas and nurse‐physician conflicts. The nurse used various strategies to promote the wishes and welfare of the laboring mother.     

Supportive Care by Maternity Nurses: A Work Sampling Study in an Intrapartum Unit

ABSTRACT: Background : This work sampling study examined how much time intrapartum unit nurses spend providing supportive care overall and during weekday and weekend shifts, and by patient and staff characteristics at a university hospital with 4000 births per year in Montréal, Québec. Methods : Four-hour observation periods were randomly selected to represent each shift and day of the week. Within each period, eight 15-minute observation times were randomly selected. Observers located each nurse assigned to the unit at that time and recorded her activity. Supportive activities included physical comfort, emotional support, instruction, and advocacy. Results : The percentage of time spent in supportive care was 6.1 percent (95% confidence interval 5.3%, 6.9%), based on 3367 observations. The time providing supportive care was similar for weekday and weekend shifts. Nurses with less than seven years of intrapartum experience spent 2.7 percent (0.9, 4.5) more time providing supportive care than nurses with seven years of experience or more. Supportive care was 9.2 percent (0.7, 17.7) greater for nulliparous than for parous women, and supportive care of women with epidural anesthesia was similar to those without it. Conclusions : We concluded that intrapartum unit nurses spent a small amount of time providing supportive care to women in labor. This suggests the need for perinatal caregivers and hospital administrators to reexamine how nurses spend their time, given the evidence from randomized trials showing the beneficial effects of continuous support on labor and birth outcomes.     

Satisfaction and Use of Prenatal Care: Their Relationship Among African‐American Women in a Large Managed Care Organization

ABSTRACT:Background: Although many more mothers of almost all ethnic groups began prenatal care in the first trimester during the last decade, a significant number of low‐income and minority women still fail to obtain adequate care in the United States—a failure that may be related to their dissatisfaction with the prenatal care experience. This study sought to examine the relationship between satisfaction with care and subsequent prenatal care utilization among African‐American women using prospective methods. Methods: A sample of 125 Medicaid and 275 non‐Medicaid African‐American adult women seeking care through a large Midwest managed care organization were interviewed before or at 28 weeks’ gestation at one of two prenatal care sites. Women were interviewed about personal characteristics, prenatal care experience, and ratings of care (satisfaction). Information about subsequent use of prenatal care was obtained through retrospective medical record review after delivery. Univariate and multivariable analyses examining the relationship between women's satisfaction and prenatal care use were conducted using a dichotomous measure of satisfaction and a continuous measure of utilization. Results: Women were highly satisfied with prenatal care, with an overall mean satisfaction score of 80.3. Non‐Medicaid women were significantly (p < 0.05) less satisfied with their prenatal care (mean score, 79.1) than Medicaid women (mean score, 82.8), and the latter had significantly fewer visits on average than the former subsequent to the interview. Analyses showed no significant difference in subsequent utilization according to whether a woman had a high versus low level of satisfaction at the prenatal care interview. Conclusions: This study challenges the assumption that improving a woman's satisfaction with care will lead to an increase in the adequacy of her prenatal care utilization. Since this study was limited to African‐American women and is the first prospective study of women's satisfaction with care and prenatal care utilization, the negative findings do not yet settle this area of inquiry. Monitoring women's satisfaction with prenatal care in both managed care and fee‐for‐service settings and working to improve those aspects of care associated with decreased satisfaction is warranted. (BIRTH 30:1 March 2003)     

Patient Safety in Midwifery Care for Low‐Risk Women: Instrument Development

Introduction: Few studies have examined the safety of midwife‐led care for low‐risk childbearing women. While most women have a low‐risk profile at the start of pregnancy, validated measures to detect patient safety risks for this population are needed. The increased interest of midwife‐led care for childbearing women to substitute for other models of care requires careful evaluation of safety aspects. In this study, we developed and tested an instrument for safety assessment of midwifery care. Methods: A structured approach was followed for instrument development. First, we reviewed the literature on patient safety in general and obstetric and midwifery care in particular. We identified 5 domains of patient risk: organization, communication, patient‐related risk factors, clinical management, and outcomes. We then developed a prototype to assess patient records and, in an iterative process, reviewed the prototype with the help of a review team of midwives and safety experts. The instrument was pilot tested for content validity, reliability, and feasibility. Results: Trained reviewers with clinical midwifery expertise applied the instrument. We were able to reduce the original 100‐item screening instrument to 32 items and applied the instrument to patient records in a reliable manner. With regard to the validity of the instrument, review of the literature and the validation procedure produced good content validity. Discussion: A valid and feasible instrument to assess patient safety in low‐risk childbearing women is now available and can be used for quantitative analyses of patient records and to identify unsafe situations. Identification and analysis of patient safety incidents required clinical judgment and consultation with the panel of safety experts. The instrument allows us to draw conclusions about safety and to recommend steps for specific, domain‐based improvements. Studies on the use of the instrument for improving patient safety are recommended.     

THE NATIONAL BIRTH CENTER STUDY Part II—Intrapartum and Immediate Postpartum and Neonatal Care

Part II of a three-part report of the National Birth Center Study describes care provided to 11,814 women and their newborns during and after labor and delivery until they were transferred or discharged from the birth centers. There were few low birth weight or preterm or postterm births, but more macrosomic babies than among all U.S. births during the same time period. Certified nurse-midwives provided most of the intrapartum care, which is described in the context of medically recommended standards and data that describe care provided to low-risk women giving birth in U.S. hospitals. Birth center care deviated from typical hospital care in several ways. Birth center clients were much less likely to receive central nervous system depressants, anesthesia, continuous electronic fetal monitoring, induction and/or augmentation of labor, intravenous infusions, amniotomies, or episiotomies, and they had relatively few vaginal examinations. They were more likely to eat solid food during labor and to take showers and/or baths Nulliparity was strongly associated with longer first stage labors and longer labor was associated with more frequent use of many kinds of interventions. Infant birth weight, mother's position during delivery, and forceps- or vacuum-assisted deliveries are examined in relation to episiotomies and lacerations and tears.