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.     

Using Emergency Obstetric Drills in Maternity Units as a Performance Improvement Tool

ABSTRACT: Background: Obstetric drills are being used increasingly to test, improve, and maintain knowledge and skills related to obstetric emergencies as a means to improve proficiency and efficiency of practitioners. The purpose of this study was to assess the feasibility and usefulness of conducting drills to evaluate the response to obstetric emergencies using a holistic approach that tested the hospital system. Methods: A prospective trial was conducted at three hospitals (two tertiary referral centers and one small community hospital) in Beirut, Lebanon. Two different emergency obstetric drills at two points in time were conducted between April and May 2006 either in the emergency room or on the labor floor. The drills included medical and paramedical staff, a female actor (simulating a pregnant woman), a research assistant (acting as her companion), and a physician trained in obstetrics (the drill leader). Responses were recorded and critically analyzed. Results: Although overall quality of care was within standards of care, problems were identified related to hospital policies, supplies and equipment, communication, and clinical management. Some technical problems related to administration of the drills were identified. Most drill participants appreciated the exercise and found it beneficial. Conclusions: Obstetric drills provide a useful tool to identify and address deficiencies in the hospital system. This finding could have implications on improving quality of care provided to obstetric patients. (BIRTH 36:1 March 2009)     

Influence of an education program of pregnant women on delivery

Abstract

Objectives: To assess whether an education program of pregnant women influences factors related to delivery and health behavior with newborns after delivery, such as the establishment of early skin-to-skin contact between the mother and newborn.

Methods: A multicenter observational study was carried out with primiparous women in four hospitals in southern Spain in 2011. Data on sociodemographic and obstetric variables were collected from interviews and clinical charts. In the analysis, crude and logistic regression adjusted odds ratios (ORs) were estimated.

Results: The study population comprised 520 women, 354 of whom attended the education program (68.1%). The program favored the establishment of early skin-to-skin contact between the mother and newborn (aOR 1.95, 95% CI 1.25–3.02, after adjusting for sociodemographic characteristics and the presence of pathology during pregnancy). Mothers who attended the program participated more actively during delivery (aOR 1.64, 95% CI 1.16–2.31). No association was observed between attending the program and the type of delivery (aOR 0.79, 95% CI 0.53–1.1) or with the frequency of cesarean section (aOR 0.81, 95% CI 0.49–1.34). The duration of delivery was also unrelated to maternal education.

Conclusions: Maternal education did not influence the type of delivery, but it favored women's participation during delivery and early skin-to-skin contact between the mother and newborn.     

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.     

Secondary Qualitative Analysis of Moral Injury in Obstetric and Neonatal Nurses

ObjectiveTo investigate the presence of symptoms of moral injury in obstetric and neonatal nurses.DesignA secondary qualitative analysis using an analytic expansion of three primary studies.SettingPostal mail and electronic surveys.ParticipantsI used three primary studies: participants in the first consisted of 78 labor and delivery nurses, participants in the second consisted of 75 nurse-midwives, and participants in the third consisted of 22 NICU nurses.MethodsI used Krippendorff’s content analysis method for qualitative data to reanalyze the three primary data sets. The categories I used in this analysis were the 10 symptoms of moral injury that are assessed by the Moral Injury Symptoms Scale–Health Professionals Version.ResultsWhen combining the three types of obstetric and neonatal participants, the top three most frequently cited symptoms of moral injury were moral concern, guilt, and self-condemnation. For participants in labor and delivery units and NICUs, moral concern was the most often described symptom, whereas for participants in midwifery it was guilt. None of the participants reported loss of meaning in their lives, loss of faith, or religious struggle. Participants who worked in NICUs did not describe any symptoms of shame or difficulty forgiving.ConclusionIn addition to the primary symptoms of moral injury, reported secondary consequences of moral injury can include depression, anxiety, anger, self-harm, and social problems. Interventions such as acceptance and commitment therapy are needed to help nurses address the potential for moral injury and repair its effects. Since the COVID-19 pandemic, now more than ever, moral injury needs to be recognized in obstetric and neonatal nurses and not just in the military population.     

Opinions regarding neonatal resuscitation training for the obstetric physician: a survey of neonatal and obstetric training program directors

Purpose: Our goal was to garner opinions regarding neonatal resuscitation training for obstetric physicians. We sought to evaluate obstacles to neonatal resuscitation training for obstetric physicians and possible solutions for implementation challenges.

Materials and methods: We distributed a national survey via email to all neonatal-perinatal medicine fellowship directors and obstetrics & gynecology residency program directors in the United States. This survey was designed by a consensus method.

Results: Ninety-eight (53%) obstetric and fifty-seven (51%) neonatal program directors responded to our surveys. Eighty-eight percent of neonatologists surveyed believe that obstetricians should be neonatal resuscitation program (NRP) certified. The majority of surveyed obstetricians (>89%) believe that obstetricians should have some neonatal resuscitation training. Eighty-six percent of obstetric residents have completed training in NRP, but only 19% of obstetric attendings are NRP certified. Major barriers to NRP training that were identified include time, lack of national requirement, lack of belief it is helpful, and cost.

Conclusions: Most obstetric attendings are not NRP certified, but the majority of respondents believe that obstetric providers should have some neonatal resuscitation training. Our study demonstrates that most respondents support a modified neonatal resuscitation course for obstetric physicians.     

Patient,provider, and system-level barriers and facilitators to addressing perinatal depression

Objective: To explore perinatal health care professionals’ perspectives on barriers and facilitators to addressing perinatal depression. Background: Perinatal depression is common and associated with deleterious effects on mother, foetus, child and family. Although the regular contact between mothers and perinatal health care professionals may make the obstetric setting ideal for addressing depression, barriers persist, and depression remains under-diagnosed and under-treated. Methods: Four 90-minute focus groups were conducted with perinatal health care professionals, including obstetric resident and attending physicians, licensed independent practitioners, nurses, patient care assistants, social workers and administrative support staff. Focus groups were transcribed, and resulting data were analysed using a grounded theory approach. Results: Participants identified patient-, provider- and system-level barriers and facilitators to addressing perinatal depression. Provider-level barriers included lack of resources, skills and confidence needed to diagnose, refer and treat perinatal depression. Limited access to mental health care and resources were identified as system-level barriers. Facilitators identified included targeted training for perinatal health care professionals’, structured screening and referral processes, and enhanced support and guidance from mental health providers. Conclusion: A complex set of interactions between women and perinatal health care professionals contributes to perinatal depression being untreated. Service gaps could be closed by addressing identified barriers through integrated obstetric and depression care and enhanced collaborations. Future intervention testing could include targeted training, improved access, and mental health provider support to empower perinatal health care professionals’ to address perinatal depression, and thereby improve delivery of depression treatment in obstetric settings.     

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.     

Ethical decision-making for extremely preterm deliveries: results of a qualitative survey among obstetricians and midwives

Objective: To explore the practices, attitudes and feelings of obstetricians and midwives in cases of extreme prematurity.

Methods: A qualitative study was conducted as part of a European Concerted Action (EUROBS) in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France. Semi-structured interviews lasted an average of 60?min and were tape-recorded. They were independently analyzed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated.

Results: Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the fetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as being more inclined than the obstetric team to initiate intensive care. If the child was born alive, intensive care was started, in the knowledge that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, in particular when there was no emergency situation. Compared with obstetricians, midwives tended to have a less favorable perception of the neonatologists' practices, and to report less parental involvement in decision-making.

Conclusions: Decisions about the obstetric management and resuscitation of extremely preterm infants are usually made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.     

Self-perceived impact of simulation-based training on the management of real-life obstetrical emergencies

Objective

To evaluate the self-perceived impact of attending a simulation-based training course on the management of real-life obstetrical emergencies.

Study design

A prospective follow-up study was conducted. Obstetric nurses and obstetricians (n = 54) from a tertiary care university hospital participated in a simulation-based training course for the management of four obstetric emergencies. One year after the last session of the course, participants were asked to complete a questionnaire evaluating the self-perceived impact it had on their knowledge, technical skills, and teamwork skills during experienced real-life situations. A five-point Likert grading scale was used. The χ² test with one degree of freedom or the Fisher's exact test were used to compare groups of participants. The t-test for independent samples was used to compare mean scores between groups.

Results

A total of 46 healthcare professionals answered the questionnaire: 27 obstetricians and 19 obstetric nurses. Of these, 87% perceived an improvement (scores 4 or 5) in their knowledge and skills during real emergencies. Obstetric nurses expressed a significantly higher improvement than obstetricians in their ability to diagnose or be aware of obstetrical emergencies (p = 0.002), in their technical skills (p = 0.024), and in their ability to deal with teamwork related issues (p = 0.005). Participants who had experienced in real-life situations all four simulated scenarios rated the impact of training significantly higher than others (p = 0.049), and also reported a better improvement in their knowledge of management guidelines (p = 0.006).

Conclusions

Healthcare professionals who participated in a simulation-based training course in obstetrical emergencies perceived a substantial improvement in their knowledge and skills when witnessing real-life emergencies. Improvements seem to be particularly relevant for obstetric nurses and for those who witness all trained obstetrical emergencies.     

Relationships Among Factors Related to Childbirth and Breastfeeding Outcomes in Primiparous Women

ObjectivesTo explore the relationships among potentially modifiable factors related to childbirth and effective breastfeeding initiation at approximately 36 hours after birth and duration and exclusivity at hospital discharge, 2 weeks, 2 months, and 6 months after birth in primiparous women and to explore whether modifiable and nonmodifiable secondary factors and covariates influenced the relationships among factors related to childbirth and these breastfeeding outcomes.DesignA prospective, longitudinal, cohort study.SettingThe postpartum units of two general hospitals in eastern Canada.ParticipantsNinety-seven mother–infant dyads.MethodsWe recorded demographic, childbirth, obstetric history, and breastfeeding data through chart review. A breastfeeding observation was completed at approximately 36 hours after birth by unit nurses. Participants maintained breastfeeding logs in hospital and for 6 months after birth and completed three self-report questionnaires before discharge. We analyzed outcomes using backward stepwise linear and logistic regression.ResultsOne childbirth factor, labor induced with oxytocin, was negatively associated with effective initiation of breastfeeding, and none was related to breastfeeding duration and exclusivity at any time point. Maternal weight; professional support; and newborn’s gestational age at birth, 5-minute Apgar score, weight loss, LATCH score, and active feeds (newborn actively suckled at the breast) were significantly associated with breastfeeding outcomes.ConclusionInduction of labor with oxytocin should be used judiciously; when used, nurses must be hypervigilant to assess the mother–infant dyad for breastfeeding issues and to intervene to prevent or remediate them.     

Intrapartal Tocolysis: An Option for Acute Intrapartal Fetal Crisis

Tocolytic drugs are commonly used by the obstetric community to produce uterine quiescence in premature labor. The use of tocolytic agents has been expanded to intrapartal emergencies. Intrapartal tocolysis has implications for obstetric nurses, which include possession of knowledge of the pharmacologic and physiologic effects of these drugs. Intrapartal tocolysis offers a beneficial management strategy that can be used in an acute intrapartal fetal crisis. The use of tocolytics provides valuable time for the health care learn to assess the etiology of a nonreassuring fetal heart rate pattern, increase options for the birth, and mobilize resources for delivery.     

Postpartum convulsions and acute hemodynamic instability in the parturient with recent amphetamine intake

Obstetric anesthesia, by definition, is a subspecialty of anesthesia dedicated (devoted) to peripartum, perioperative, pain and anesthetic management of women during pregnancy and the puerperium. Today, obstetric anesthesia has become a recognized subspecialty of anesthesiology and an integral part of practice of most anesthesiologists. Perhaps no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. An obstetric anesthesiologist has become an essential member of the obstetric care team, who closely works with the obstetrician, midwife, neonatologist and labor and delivery nurse to ensure the high-quality care for the parturient and her baby. Communication skills and exchange of information in ever changing environment of labor and delivery is essential for perfect outcome, which is always expected when providing safe passage for both the mother and her fetus from antepartum to postpartum period. The anesthesiologist’s unique skills in acute resuscitation combined with experience in critical care make members of this subspecialty of anesthesiology particularly valuable in peripartum care of the high-risk patients, extending the anesthesiologist’s role well beyond the routine provision of intrapartum anesthesia or analgesia.     

Etiologies and contributing factors of perinatal mortality: a report from southeast of Iran

ObjectiveThe aim of this study was to investigate the etiology and risk factors of perinatal mortality in Rafsanjan, Iran.Materials and methodsThis case-control prospective study was conducted on 321 perinatal deaths (as case group) and 321 live births who were alive until 28 days after birth (as control group) during a 2-year period. Data about demographic characteristics of mother, fetus, and newborn and also mother’s obstetrics and clinical status was recorded in a questionnaire.ResultsThe most important causes of newborn death were prematurity (63.24%), cardiac arrest (11.49%), and septicemia (5.75%) as well as premature rupture of membrane, pregnancy-induced hypertension, placenta decolman, and congenital abnormality for stillbirth. A significant association was found among the fetal weight, gestational age, and amniotic fluid volume with stillbirth.ConclusionPrematurity, cardiac arrest, and septicemia were the most important causes of neonatal mortality. It is concluded that attention to the following points is very important: adopting program for pregnancy care improvement, finding and removing risk factors of premature birth, control of infection in mother’s and newborn’s wards, examining of personnel skill about correct newborn resuscitation methods, and arrangement of training courses.     

Does Residency Training Improve Cognitive Competence in Obstetric and Gynaecologic Surgery?

ObjectiveTo develop an operative knowledge assessment tool to evaluate the cognitive competence of trainees in obstetric and gynaecologic surgery and to determine the rate of change in competence during a five-year residency program.MethodsTwenty-eight participants in five training groups (PGY-1 to PGY-5) in McGill University’s residency program in obstetrics and gynaecology underwent an evaluation based on surgical cognitive competence (SCC) assessment tools developed for three different obstetric and gynaecologic operations: open total abdominal hysterectomy (TAH), Caesarean section, and laparoscopic bilateral tubal sterilization (BTL). The tools were developed as checklists listing every step in each operation based on techniques described in current surgical texts. Using analysis of variance and linear regressions, statistical significance was established for procedure-specific scores and overall SCC scores. In addition, the rate of change of cognitive competence throughout the training years was calculated. Finally, using a t test, the overall SCC score was compared to a “critical steps score.”ResultsCritical steps scores and overall SCC scores increased with training experience at an average yearly rate of 13.36% (P < 0.001). Procedure-specific scores increased yearly, by 15.73% for TAH (P < 0.001), 8.06% for Caesarean section (P < 0.001), and 16.31% for BTL (P < 0.001). The difference between overall scores and critical steps scores was not statistically significant for the study cohort (P = 0.94).ConclusionSurgical cognitive competence among obstetrics and gynaecology residents can be reliably assessed with our evaluation tool, and it increases proportionally with residency education, reaching maximum scores during the final year of training. This type of information may be helpful in ascertaining how long a residency program should be.     

Economic implications of method of delivery

OBJECTIVE: This study was undertaken to examine the costs of hospital care associated with different methods of delivery. STUDY DESIGN: An 18-year population-based cohort study (1985-2002) using the Nova Scotia Atlee Perinatal Database compared outcomes in nulliparous women at term undergoing spontaneous or induced labor for planned vaginal delivery, or undergoing cesarean delivery without labor. Costs that were assessed included physician fees, nursing hours in the labor and delivery, postpartum and neonatal intensive care units, epidural use, induction of labor agents, and consumables. RESULTS: A total of 27,614 pregnancies satisfied inclusion and exclusion criteria, 5233 of which had labor induced. A comparison of mean costs per mother/infant pair demonstrated that cesarean delivery in labor ($2137) was increased compared with spontaneous vaginal delivery ($1340, P=.01), assisted vaginal delivery ($1594, P=.01), and cesarean delivery without labor ($1532, P=.01). The cost of delivery after induction of labor ($1715) was increased compared with spontaneous onset of labor ($1474, P<.001). CONCLUSION: Cesarean delivery in labor occurs more frequently with labor induction and is associated with increased costs compared with other methods of delivery.     

Recurrent obstetric management mistakes identified by simulation

OBJECTIVE: To develop a simulation-based curricular unit for labor and delivery teams involved in obstetric emergencies to detect and address common mistakes. METHODS: A simulation-based curricular unit for hands-on training of four obstetric emergency scenarios was developed using high-tech mannequins and low-tech simulators. The scenarios were eclamptic seizure, postpartum hemorrhage, shoulder dystocia, and breech extraction. The obstetric teams consisted of at least one resident and two midwives. Checklists of actions expected from the teams were handed out to the course's tutors who observed the "event." All sessions were videotaped and then reviewed and analyzed by the trainees themselves, who were guided by two experienced tutors. We identified the most commonly occurring mistakes by summing up checklists and by watching the recorded sessions. RESULTS: Between February 2004 and April 2006, 60 residents in obstetrics and gynecology and 88 midwives underwent the simulation-based course. Forty-two labor and delivery teams completed all four sessions. The most common management errors were delay in transporting the bleeding patient to the operating room (82%), unfamiliarity with prostaglandin administration to reverse uterine atony (82%), poor cardiopulmonary resuscitation techniques (80%), inadequate documentation of shoulder dystocia (80%), delayed administration of blood products to reverse consumption coagulopathy (66%), and inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction (32%). Eighteen trainees were invited for repeated sessions at least 6 months after the first training day, and their scores were significantly higher in the latter sessions (79.4+/-4.3 versus 70+/-5.3 for the second and first simulated eclampsia sessions). CONCLUSION: A curricular unit based on simulation of obstetric emergencies can identify pitfalls of management in labor and delivery rooms that need to be addressed.