Perceptions of Safety Improvement Among Clinicians Before and After Participation in a Multistate Postpartum Hemorrhage Project

Objective

To measure whether implementation of a comprehensive, 18-month, multihospital, multiregion postpartum hemorrhage (PPH) project influenced intrapartum clinicians’ perceptions of patient safety.

Randomized Controlled Simulation Trial to Compare Transfer Procedures for Emergency Cesarean

ObjectiveTo test the hypothesis that capping intravenous and epidural lines would reduce time to transfer women in labor to the operating room and time to readiness for general anesthesia for emergency cesarean. The secondary purpose was to identify latent threats to patient safety.DesignMixed methods analysis of a randomized, controlled, in situ simulation trial.SettingLabor and delivery unit at high-risk referral center.ParticipantsFifteen interprofessional teams that included labor and delivery nurses and anesthesiology residents.MethodsImmediately before simulation, we randomized bedside nurses and anesthesiology residents to one of two groups: usual transfer or the cap and run procedure. Simulation scenarios started with fetal heart rate decelerations that necessitated position changes followed by emergency cesarean. An embedded simulated obstetrician announced the decision for cesarean; completion of an OR checklist confirmed team readiness to induce general anesthesia. Postsimulation debriefing was focused on teamwork and opportunities to improve safety, and we used qualitative analysis to synthesize results.ResultsWe found no statistically significant difference in the overall time from decision for cesarean to readiness for general anesthesia between the two groups (usual transfer median = 445 seconds [interquartile range, 425–465] vs. cap and run 390 seconds [interquartile range, 383–443], p = .12). The time in the operating room was less in the cap and run group than in the usual transfer group (median = 300 seconds vs. 250 seconds, p = .038). Qualitative analysis of the debriefing data indicated advantages of the capping procedure, including better bed maneuverability and fewer tangled lines.ConclusionWe found no evidence of decreased overall time from decision for cesarean to readiness for general anesthesia based on whether the nurse capped the intravenous and epidural lines or pushed the intravenous pole alongside the bed. However, nurses perceived improved patient safety with the cap and run procedure.     

The Role of Women's Attitudinal Profiles in Satisfaction with the Quality of their Antenatal and Intrapartum Care

ObjectiveTo compare perceptions of antenatal and intrapartum care in women categorized into three profiles based on attitudes and fear.DesignProspective longitudinal cohort study using self-report questionnaires. Profiles were constructed from responses to the Birth Attitudes Profile Scale and the Fear of Birth Scale at pregnancy weeks 18 to 20. Perception of the quality of care was measured using the Quality from Patient's Perspective index at 34 to 36 weeks pregnancy and 2 months after birth.SettingTwo hospitals in Sweden and Australia.ParticipantsFive hundred and five (505) pregnant women from one hospital in Västernorrland, Sweden (n = 386) and one in northeast Victoria, Australia (n = 123).ResultsWomen were categorized into three profiles: self-determiners, take it as it comes, and fearful. The self-determiners reported the best outcomes, whereas the fearful were most likely to perceive deficient care. Antenatally the fearful were more likely to indicate deficiencies in medical care, emotional care, support received from nurse-midwives or doctors and nurse-midwives’/doctors’ understanding of the woman's situation. They also reported deficiencies in two aspects of intrapartum care: support during birth and control during birth.ConclusionsAttitudinal profiling of women during pregnancy may assist clinicians to deliver the style and content of antenatal and intrapartum care to match what women value and need. An awareness of a woman's fear of birth provides an opportunity to offer comprehensive emotional support with the aim of promoting a positive birth experience.     

The Attitudes of Canadian Maternity Care Practitioners Towards Labour and Birth: Many Differences but Important Similarities

ObjectiveCollaborative, interdisciplinary care models have the potential to improve maternity care. Differing attitudes of maternity care providers may impede this process. We sought to examine the attitudes of Canadian maternity care practitioners towards labour and birth.MethodsWe performed a cross-sectional web- and paper-based survey of 549 obstetricians, 897 family physicians (400 antepartum only, 497 intrapartum), 545 nurses, 400 midwives, and 192 doulas.ResultsParticipants responded to 43 Likert-type attitudinal questions. Nine themes were identified: electronic fetal monitoring, epidural analgesia, episiotomy, doula roles, Caesarean section benefits, factors decreasing Caesarean section rates, maternal choice, fear of vaginal birth, and safety of birth mode and place. Obstetrician scores reflected positive attitudes towards use of technology, in contrast to midwives’ and doulas’ scores. Family physicians providing only antenatal care had attitudinal scores similar to obstetricians; family physicians practising intrapartum care and nurses had intermediate scores on technology. Obstetricians’ scores indicated that they had the least positive attitudes towards home birth, women’s roles in their own births, and doula care, and they were the most concerned about the consequences of vaginal birth. Midwives’ and doulas’ scores reflected opposing views on these issues. Although 71% of obstetricians supported regulated midwifery, 88.9% were against home birth. Substantial numbers of each group held attitudes similar to dominant attitudes from other disciplines.ConclusionTo develop effective team practice, efforts to reconcile differing attitudes towards labour and birth are needed. However, the overlap in attitudes between disciplines holds promise for a basis upon which to begin shared problem solving and collaboration.     

Improving Nurse Self-Efficacy and Increasing Continuous Labor Support With the Promoting Comfort in Labor Safety Bundle

ObjectiveTo increase nurse self-efficacy and the use of continuous labor support and to reduce the rate of primary cesareans among nulliparous women with low-risk pregnancies by implementing the Promoting Comfort in Labor safety bundle.DesignA quality improvement project with a pre–post practice implementation design. This practice change was part of the Reducing Primary Cesarean Learning Collaborative from the American College of Nurse-Midwives.SettingA Level II regional hospital in Virginia with more than 2,600 births annually. Births are attended by certified nurse-midwives and physicians.ParticipantsNursing staff on the labor and delivery unit in March 2016 (n = 27), September 2017 (n = 20), and June 2019 (n = 24).Intervention/MeasurementsWe updated policies, educated nurses, procured labor support equipment, and modified documentation of care. We measured nurse confidence and skill in labor support techniques with the Self-Efficacy Labor Support Scale over 4 years. We tracked how many women were provided continuous labor support and the primary cesarean birth rate among women who were nulliparous and low risk.ResultsNurses’ mean self-efficacy scores increased from 76.67 in 2016 to 86.96 in 2019 (p < .001). The proportion of women who were provided continuous labor support increased from a baseline of 4.38% (47/1,074) in January 2015 through March 2016 to 18.06% (82/454) in July through December 2019 (p < .001). The primary cesarean birth rate for nulliparous women with low-risk pregnancies remained stable, at approximately 18% from 2015 to 2019.ConclusionImplementation of the Comfort in Labor Safety Bundle improved nurse self-efficacy in labor support techniques and increased the frequency of continuous labor support.     

Nurses’ Perspectives on the Intersection of Safety and Informed Decision Making in Maternity Care

ObjectiveTo explore maternity nurses’ perceptions of women's informed decision making during labor and birth to better understand how interdisciplinary communication challenges might affect patient safety.DesignConstructivist grounded theory.SettingFour hospitals in the western United States.ParticipantsForty‐six (46) nurses and physicians practicing in maternity units.MethodData collection strategies included individual interviews and participant observation. Data were analyzed using the constant comparative method, dimensional analysis, and situational analysis (Charmaz, 2006; Clarke, 2005; Schatzman, 1991).ResultsThe nurses’ central action of holding off harm encompassed three communication strategies: persuading agreement, managing information, and coaching of mothers and physicians. These strategies were executed in a complex, hierarchical context characterized by varied practice patterns and relationships. Nurses’ priorities and patient safety goals were sometimes misaligned with those of physicians, resulting in potentially unsafe communication.ConclusionsThe communication strategies nurses employed resulted in intended and unintended consequences with safety implications for mothers and providers and had the potential to trap women in the middle of interprofessional conflicts and differences of opinion.     

Advancing obstetric anesthesia practices in Georgia through clinical education and quality improvement methodologies

ObjectiveTo determine whether an integrated program of clinical education and improvement methods regarding the safe use of regional anesthesia for obstetrics would result in improved and sustained practice change in Georgia.MethodsBetween 2006 and 2009, intervention teams undertook several visits to 5 Georgian hospitals. Rates of regional anesthesia for labor and cesarean delivery prior to and following the intervention were collected from participating and non-participating hospitals. There were multifaceted educational activities and quality improvement activities at intervention sites, including protocol development, social marketing, and supply chain logistics. Host hospitals evaluated the program via a questionnaire.ResultsThe use of general anesthesia for cesarean delivery decreased significantly (P < 0.001) and the use of epidural analgesia for labor increased significantly (P < 0.001); there was no change in non-participating hospitals. Over the course of the program, medication and supply availability improved. Program evaluations were uniformly positive.ConclusionA structured program of education and quality improvement led to an increase in the use of regional anesthesia for vaginal and cesarean deliveries. Achievements were sustained during periods of economic and political turmoil.     

Pubic Symphysis Separation and Regression in Vaginal versus Cesarean Delivery

ObjectiveTo quantify the association of pubic symphysis separation with mode of delivery and follow the resolution of this physiologic separation in the postpartum period.MethodsProspective observational cohort study that recruited two cohorts of primiparous women: those undergoing vaginal and cesarean delivery (45 and 46 patients, respectively). Chart review collected intrapartum factors. Patients were followed with serial anterior-posterior radiographs within 48 hours of delivery and at 6, 12, and 24 weeks postpartum, to evaluate the extent of pubic symphysis separation. Differences between the two cohorts in intrapartum factors were assesses as was pubic symphysis separation at each time point.ResultsMean age of women was 25.8 (SD 5.1) years, and 56% were White. Mean birth weight was 3.5 (SD 0.52) kg. Mean immediate postpartum pubic symphysis separation was 7.6 (SD 2.2) mm and did not differ between groups, at 7.18 mm for vaginal delivery versus 8.04 mm for cesarean delivery (CD; P = 0.08). Pubic symphysis separation was not significantly different for CD with and without labour. Black race and obesity were associated with increased pubic symphysis separation. No intrapartum events were related to extent of separation. Normalization of pregnancy pubic symphysis separation to 4–5 mm occurred by 6 weeks postpartum. Separation of >10mm and <15mm occurred in 10 of the 91 women and occurred after vaginal and cesarean delivery. The widest pubic symphysis separation was observed in 3 patients after vaginal delivery.ConclusionPhysiological pubic symphysis separation occursduring pregnancy and regresses postpartum with minimal effects from labour and delivery. Cesarean deliverydoes not prevent physiological pubic symphysis separation.     

Cesarean Delivery in Adolescents

Study ObjectiveTo examine the effect of maternal age on indication for primary cesarean delivery in low-risk nulliparous women.DesignRetrospective cohort study.SettingUrban academic tertiary care center.ParticipantsNulliparous women younger than 35 years of age delivering vertex-presenting singletons at term.InterventionsParticipants underwent spontaneous, operative or cesarean delivery.Main Outcome MeasuresMode of delivery, indication, and timing of cesarean delivery.ResultsAdolescents were half as likely to undergo cesarean delivery overall (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.43-0.54), and more than one-third less likely to undergo cesarean delivery in labor (OR, 0.59; 95% CI, 0.53-0.66). Adjustment for potential confounders did not alter the strength of these associations. Adolescents were half as likely to undergo cesarean delivery for failure to progress (OR, 0.49; 95% CI, 0.43-0.54). There was no difference in the odds of cesarean delivery for nonreassuring fetal status (OR, 0.91; 95% CI, 0.77-1.06), or genital herpes (OR, 1.44; 95% CI, 0.57-3.68). Induction, macrosomia, oxytocin augmentation, and any labor complication were all associated with increased risk of cesarean delivery. There was no difference in the duration of second stage for adolescents who delivered by cesarean delivery compared with adults (240.0 vs 237.7 minutes; P = .84), but adolescents who delivered vaginally had a second stage that was one-third shorter than adults (62.5 vs 100.3 minutes; P < .001).ConclusionAdolescents are half as likely to undergo primary cesarean delivery overall, and 40% less likely to undergo a primary cesarean delivery in labor, even after adjustment for multiple maternal, neonatal, and labor characteristics. This difference is not explained by differences in the duration of the second stage of labor.     

Factors Associated with Differences in Canadian Perinatal Nurses’ Attitudes Toward Birth Practices

ObjectiveTo test whether demographic characteristics predict registered nurses’ attitudes toward birth practices.DesignA secondary analysis of a cross‐sectional survey, the National Maternity Care Attitudes Survey.SettingA national survey conducted with health care providers providing maternity care in Canada.ParticipantsA convenience sample of 545 registered nurses.MethodsHierarchical regression analysis was used to examine three hypotheses about nurses’ demographic differences in relationship to their attitudes toward birth practices. Attitude scales included acceptability of doulas, effects of routine electronic fetal monitoring, factors decreasing cesarean birth rates, the importance of vaginal birth for women, safety of birth, episiotomy, and epidural analgesia.ResultsTertiary hospital–level of employment was associated with more positive attitudes toward epidural analgesia and less positive attitudes toward the importance of vaginal birth. Nurses working at a tertiary hospital were more likely to select an obstetrician for their own maternity care. Those who worked at a community hospital were more likely to select a family physician. Nurses’ selection of an obstetrician was associated with less positive attitudes toward the safety of birth and importance of vaginal birth and more positive attitudes toward electronic fetal monitoring, episiotomy, and epidural analgesia.ConclusionNurses’ attitudes may be influenced by exposure in their workplaces to predominant care providers’ birth practices. Research examining the relationships between nurses’ workplace exposures, attitudes, and practice behaviors is needed to develop understanding about how nurses contribute to rates of intervention in maternity care.     

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.