Effects of labor support on mothers,babies, and birth outcomes

Supportive care and childbirth have been connected for all of recorded history. The impact of supportive care on health outcomes, however, has only been investigated over the last few decades. Research provides powerful evidence of improved outcomes for mothers and babies when mothers are supported in labor. These outcomes include, but are not limited to, lower rates of analgesia and anesthesia use, lower operative birth rates, shorter labors, fewer newborns with 5-minute Apgar scores less than 7, increased maternal satisfaction with the birthing process, and much more. Intrapartum nurses must be knowledgeable of the research that is directly related to critical aspects of their care, such as labor support. This article provides an overview of the quantitative research related to the effect of labor support on birth and maternal and fetal outcomes during childbirth. By understanding and applying this research in clinical practice, bedside nurses may improve outcomes and transform intrapartum care.     

Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses

OBJECTIVE: To test the effectiveness of an evidence-based clinical practice guideline for neonatal skin care on selected clinical outcomes for newborns in neonatal intensive-care units (NICU), special-care units (SCU), and well-baby nurseries. DESIGN: Prospective evaluation of the collaborative neonatal skin care research-based practice project of the Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. SETTING: NICU and well-baby units in 51 hospitals located throughout the United States. PARTICIPANTS: Member site coordinators (N = 51) and the neonates (N= 2,820) observed during both the pre- and postimplementation phases of the project. METHOD: Site coordinators received specialized education in neonatal skin care and implemented an evidence-based clinical practice guideline addressing 10 aspects of neonatal skin care. Baseline observations of skin condition, care practices, and environment of newly admitted neonates were collected by site coordinators. Postimplementation observations were then completed. MAIN OUTCOME MEASURES: Skin condition was assessed with the Neonatal Skin Condition Score (NSCS), which ranges from a score of three (best condition) to a score of nine (worst condition), based on dryness, erythema, and skin breakdown. Changes in frequency of selected skin care practices were used to assess the effectiveness and feasibility of using the practice guideline in everyday clinical practice. Aspects of the care environment with potential effect on skin integrity were monitored to determine risk factors. RESULTS: Fifty-one site coordinators made 11,468 systematic assessments of 2,464 NICU and SCU newborns and 356 well newborns. Baseline skin scores were better in well newborns compared with premature newborns. After implementation of the guideline, skin condition was improved, as reflected by less visible dryness, redness, and skin breakdown in both the NICU/SCU and well newborns. The guideline was integrated into care, as evidenced by increased use of emollients, particularly with premature infants, and decreased frequency of bathing. A relationship was shown between selected aspects of the environment and alterations in skin integrity. CONCLUSIONS: Use of the AWHONN/NANN Neonatal Skin Care Research-Based Clinical Practice Guideline was successfully implemented at 51 sites, and effectiveness was demonstrated by changed care practices and improved skin condition in premature and full-term newborns. The results of this project support a wider dissemination of the project's practice guideline for neonatal skin care.     

A quasi-experimental trial on individualized, developmentally supportive family-centered care

OBJECTIVE: To evaluate the impact of individualized, developmentally supportive family-centered care on infant physiological variables, growth, behavioral stress cues, return to sleep state, medical and developmental progress, complications, resource utilization, parental perception of the neonatal intensive-care unit experience, and overall parental satisfaction. DESIGN: Quasi-experimental, repeated measures design. SETTING: Developmental and a control nursery in a 78-bed, level II/III neonatal intensive-care unit. PARTICIPANTS: A convenience sample of 114 premature infants and their parents. INTERVENTIONS: Control group infants received the routine neonatal intensive-care unit standard of care. Experimental infants received routine care plus the addition of individualized, developmentally supportive family-centered interventions. MAIN OUTCOME MEASURES: Between groups, there were no statistically significant differences in demographic factors, days to medical or developmental milestones, length of stay, or direct cost/case. Repeated measures analysis of variance determined that at every point of data collection, the average number of baseline, activity, and postactivity stress cues were lower in the developmentally supportive group. Infants in the developmental group had 8% less sedatives/narcotics and 15% less vasopressors costs than the control group. There were no differences in complication rates, parental perceptions of the neonatal intensive-care unit experience, or parental satisfaction between groups. CONCLUSIONS: Preterm infants who received developmentally supportive family-centered care demonstrated fewer behavioral stress cues and comparable short-term outcomes and resource utilization than infants who received routine care.     

Specialized care for twin gestations: improving newborn outcomes and reducing costs

OBJECTIVE: To compare newborn outcomes and costs of hospital stays for twins born to mothers receiving care in a specialized twin clinic with a research-based care protocol and one consistent caregiver versus twins whose mothers received standard prenatal care. DESIGN AND SETTING: A retrospective, historical cohort study conducted in a high-risk obstetric clinic in central Texas. PATIENTS: Thirty women pregnant with twins received specialized care. The comparison group consisted of 41 women pregnant with twins who received standard care. INTERVENTIONS: An advanced practice nurse provided prenatal care, which included weekly clinic visits, home visits, and 24-hour availability for phone support. OUTCOME MEASURES: Gestational age at birth, birth weight, length of stay in the neonatal intensive-care unit (NICU), and hospital charges for the newborns. RESULTS: No newborns of less than 30 weeks gestation were born to women in the specialized care group, the mean birth weight was 249 g (SD +/- 77) higher, days in the NICU were reduced from a mean of 17 to 7, and hospital charges were $30,000 less per infant. CONCLUSIONS: Newborn outcomes were improved and length of stay and hospital charges were significantly reduced for newborns whose mothers had received care in the specialized twin clinic.     

剖宫产术新生儿早期基本保健技术临床实施建议

2013年,世界卫生组织(World Health Organization,WHO)西太平洋地区(简称西太区)办公室提出了“新生儿早期基本保健(early essential newborn care,EENC)技术”的概念,旨在减少新生儿死亡和改善新生儿结局。2016年我国引入EENC。既往EENC的临床实施建议和专家共识主要针对经阴道分娩的新生儿。在WHO西太区和联合国儿童基金会驻华办事处的支持下,WHO妇儿保健研究培训合作中心牵头,联合北京大学第一医院、西北妇女儿童医院、四川省妇幼保健院和宁夏医科大学总医院等4家医院开展了剖宫产术EENC的临床研究,并在基于循证医学证据和实践经验基础上撰写本实施建议。希望通过本实施建议,可以帮助有条件的医疗机构开展剖宫产术EENC。本临床实施建议第一部分为根据国内试点地区试行情况制定的剖宫产术EENC实施流程;第二部分为剖宫产术EENC相关技术的循证医学证据。     

The admission rate in neonatal intensive care units of newborns born to adolescent mothers

Aim.?Although the effect of adolescent pregnancy on perinatal mortality and morbidity is known, data on the neonatal hospitalization rate in these deliveries have not been reported. We aimed to assess the possible effects of adolescent pregnancies on the hospital outcomes of the newborns.

Methods.?Three hundred adolescent mothers under 17 years of age and their singleton newborns were enrolled in this retrospective study. The major outcomes of the study were the rates of prematurity and intrauterine growth retardation, and the admission rate of newborns to the neonatal intensive care unit.

Results.?Twenty-nine percent of the newborns were premature, and the intrauterine growth retardation rate was 1%. Forty-one newborns (13.6%), of whom 38 (92.6%) were preterm, were admitted to the neonatal intensive care unit. The admission rate of the study population was higher than the overall newborn neonatal intensive care unit admission rate for our hospital of 9.7% (p?<?0.05).

Conclusion.?The rates of prematurity and neonatal intensive care unit admission were higher in adolescent mothers. This study is the first to demonstrate that the high NICU admission rate was related to premature deliveries in this group.     

Unequal care: Racial/ethnic disparities in neonatal intensive care delivery

Advances in neonatal intensive care have improved outcomes for preterm newborns, but significant racial/ethnic disparities persist. Neonatal disparities have their origin in a complex set of factors that include systemic racism and structural disadvantages endured by minority families, but differential quality of care in the neonatal intensive care unit (NICU) remains an important and modifiable source of disparity. NICU care has been shown to be segregated and unequal: Black and Hispanic infants are more likely to be cared for in lower quality NICUs and may receive worse care within a NICU. To eliminate disparities in care and outcomes, it is important to identify and address the mechanisms that lead to lower quality care for minority preterm infants. In this review, we identify improvements in both technical (clinical) and relational (engaging and supporting families) processes of care as critical to better outcomes for minority infants and families.     

Culturally competent care of women and newborns: knowledge, attitude, and skills

In a variety of health care settings throughout the United States and Canada, nurses are caring for women and newborns from culturally diverse backgrounds. In the technologically complex and bureaucratic world of health care delivery, cultural considerations in provision of care often are overlooked and neglected. The purpose of this article is to define ways in which culturally competent nursing care can be implemented. Nursing education and clinical practice guidelines are clear on the importance of gaining cultural competence. Providing culturally competent care includes understanding the dimensions of culture; moving beyond the biophysical to a more holistic approach; and seeking to increase knowledge, change attitudes, and hone clinical skills. Building on the strengths of women rather than utilizing a deficit model of health care is an essential part of providing culturally competent care. The achievement of both measurable and "soft" outcomes related to the delivery of culturally competent care can make a critical difference in the heath and well-being of women and newborns.     

Access to risk-appropriate hospital care and disparities in neonatal outcomes in racial/ethnic groups and rural–urban populations

Variations in infant and neonatal mortality continue to persist in the United States and in other countries based on both socio-demographic characteristics, such as race and ethnicity, and geographic location. One potential driver of these differences is variations in access to risk-appropriate delivery care. The purpose of this article is to present the importance of delivery hospitals on neonatal outcomes, discuss variation in access to these hospitals for high-risk infants and their mothers, and to provide insight into drivers for differences in access to high-quality perinatal care using the available literature. This review also illustrates the lack of information on a number of topics that are crucial to the development of evidence-based interventions to improve access to appropriate delivery hospital services and thus optimize the outcomes of high-risk mothers and their newborns.     

Getting to know you: mothers' experiences of kangaroo care

OBJECTIVE: To reveal mothers' experiences of providing kangaroo care for their preterm newborns while still in the hospital. DESIGN: Transcendental phenomenology was used to analyze the experiences of mothers providing kangaroo care for their preterm newborns. Tape recorded, semistructured interviews were conducted 1 to 4 weeks postpartum. Mothers were asked one grand tour question, "What was it like for you to provide kangaroo care for your preterm infant while in the hospital?" This study was the qualitative component of a randomized clinical trial. PARTICIPANTS: Ten women who provided kangaroo care for their preterm newborns, 32-36 completed weeks, weighing 1500-3000 grams, with APGAR scores 6 or greater at 1 minute, 7 or greater at 5 minutes. RESULTS: Four dominant themes emerged. The themes were reduced to one essential structure of knowing. The two essential elements of the structure of knowing were mothers kept from knowing their preterm newborn and mothers getting to know their preterm newborn. CONCLUSIONS: Kangaroo care facilitates bonding and enhances maternal-infant acquaintance, even in the neonatal intensive care unit (NICU) environment. Mothers found that kangaroo care calmed them and their newborns.     

Effect of training for care providers on practice of essential newborn care in hospitals in Sri Lanka

OBJECTIVE: To evaluate the effectiveness of a training program for care providers in improving practice of essential newborn care in obstetric units. DESIGN: Before-and-after study with an intervention and a control group. SETTING: Five hospitals in the Puttalam district in Sri Lanka. PARTICIPANTS: Eight hundred and ninety-two mother-newborn pairs (446 before and 446 three months after). INTERVENTION: A 4-day training program on essential newborn care for doctors, nurses, and midwives of the obstetric units in two hospitals. MAIN OUTCOME MEASURES: By direct observation, practices of essential newborn care at delivery in the labor room on a subsample. By interviewing mothers, immediate skin-to-skin contact and early initiation of breastfeeding. From health records, "undesirable health events" of the newborns. RESULTS: Practices of cleanliness, thermal protection, and neonatal assessment improved significantly in the intervention group. The intervention was effective in improving skin-to-skin contact by 1.5 times and early initiation of breastfeeding by 3.4 times. Undesirable health events declined from 32 to 21 per 223 newborns in the intervention group and from 20 to 17 per 223 newborns in the control group. CONCLUSION: A comprehensive 4-day training program can be followed by a significant improvement in essential newborn care practices in obstetric units.     

Birth attendants trained in "Prevention of Mother-To-Child HIV Transmission" provide care in rural Cameroon, Africa

Since 1984, Cameroon Baptist Convention Health Board's Life Abundant Primary health care program has established primary health centers in remote villages and trained literate women in these villages as birth attendants to offer antenatal care, low-risk delivery, and triage of high-risk mothers to larger health facilities. In 2002, the birth attendants were trained to provide Prevention of Maternal-to-Child HIV Transmission (PMTCT) services, including counseling, voluntary testing, performing oral rapid HIV tests (OraQuick; OraSure Technologies, Inc., Bethlehem, PA), posttest counseling, and administering single-dose nevirapine to HIV-positive women, to be taken in labor, and to their newborns. Ongoing supervision is provided by nurse supervisors. Between July 2002 and June 2005, 30 PMTCT-trained birth attendants in 20 villages counseled 2331 pregnant women and tested 2310 (99.1%) for HIV. Eighty-two women had a positive OraQuick HIV test (3.5%). Forty-two of these mothers were delivered by the trained birth attendants, with 88.1% of mothers and 85.7% of newborns receiving single-dose nevirapine prophylaxis. Nevirapine-treated babies were tested after 15 months of age, and two of 13 HIV-exposed infants had a positive rapid HIV antibody test (15.3% transmission rate with treatment). Program challenges include: maintaining adequate supplies of HIV tests kits and medications, supervising and supporting the PMCT-trained birth attendants on a regular basis, and achieving exclusive breastfeeding and early weaning.     

Long-term survival from gynecologic cancer: psychosocial outcomes, supportive care needs and positive outcomes

OBJECTIVES: To assess the long-term psychosocial outcomes and supportive care needs of gynecologic cancer survivors. METHODS: Women who had received care in a tertiary-based gynecologic cancer center 1-8 years earlier and who were disease-free were invited to complete a mailed self-report questionnaire to assess psychosocial outcomes and supportive care needs. RESULTS: In total, 199 survivors participated in the study. Survivors reported normal quality of life and relationship adjustment although functioning was at the lower end of the range; over two-thirds (68%) reported positive outcomes. However, nearly one-third (29%) reported clinical levels of anxiety and the most frequently endorsed need concerned fear of disease recurrence (24%). About one-fifth (19%) reported symptoms that indicated posttraumatic stress disorder (PTSD) and this rose to close to one-third (29%) for survivors of advanced stage disease. Nearly 90% of survivors reported supportive care needs and the diagnosis of anxiety or PTSD resulted in a four-fold increase in unmet needs. Needs most frequently concerned "existential survivorship" (e.g., spiritual beliefs, decision making, the meaning of life) and "comprehensive cancer care" (e.g., team care, communication, local health care services). Years since diagnosis was not related to distress or need levels. CONCLUSIONS: All members of the care team need to be aware that significant psychosocial morbidity may occur many years after the successful treatment of a gynecologic malignancy and may be associated with elevated supportive care needs. Comprehensive and extended supportive care services are required to address anxiety and trauma responses and investigate strategies to meet ongoing needs in order to improve long-term psychosocial outcomes.     

Maternity care access,quality, and outcomes: A systems-level perspective on research,clinical, and policy needs

The quality of maternity care in the United States is variable, and access to care is tenuous for rural residents, low-income individuals, and people of color. Without accessible, timely, and high-quality care, certain clinical and sociodemographic characteristics of individuals may render them more vulnerable to poor birth outcomes. However, risk factors for poor birth outcomes do not occur in a vaccum; rather, health care financing, delivery, and organization as well as the policy environment shape the context in which patients seek and receive maternity care. This paper describes the relationship between access and quality in maternity care and offers a systems-level perspective on the innovations and strategies needed in research, clinical care, and policy to improve equity in maternal and infant health.     

Physiologic Breastfeeding: A Contemporary Approach to Breastfeeding Initiation

Early initiation of breastfeeding has numerous benefits for maternal‐child health. Maternity care providers have been shown to play a significant role in establishing breastfeeding, yet there is limited research about clinical approaches that support breastfeeding initiation in the immediate postpartum. Traditional methods that focused on position and attachment have not demonstrated consistent, positive effects on breastfeeding outcomes. Contemporary approaches to breastfeeding initiation emphasize innate maternal and neonatal breastfeeding abilities and the importance of breastfeeding self‐efficacy, dyad‐centered care, and a supportive breastfeeding environment free from unnecessary interventions. Recommendations for clinical practice for physiologic breastfeeding initiation are provided.     

Periviable babies: Italian suggestions for the ethical debate

With the advancement of medical technology, the outcomes for high-risk infants have greatly improved. However, hand and hand with the more positive result of saving neonates, modern neonatal intensive care has also brought to light several issues regarding the ethical grounds in infant care. One of the greatest problems concerns newborns at the threshold of viability. Treatment guidelines have been formulated for these babies in different countries all around the world and there is the general consensus to withhold resuscitation in neonates when gestational age in less than, or equal to 23 weeks, with intensive care ensured for infants at 25 weeks' gestational age. In order to provide helpful suggestions during the initial management of the threatened birth of an infant with a gestational age of 25 completed weeks or less, we conducted a study for reviewing international studies on survival and morbidity rates, international guidelines and practice recommendations. This gave rise to the creation of a consensus document subsequently submitted to the Italian Scientific Societies for approval. The ‘Carta di Firenze’ does not attempt to deal with the problems related to pediatric euthanasia or eugenetics: its aim is to protect the infant and the mother from undue suffering although addressing recommendations for the work of clinicians.     

Comparison of health care utilization of postnatal programs in Sweden

OBJECTIVE: To describe the utilization of health care services, based on number of outpatient visits and readmissions, by mothers and newborns following discharge postnatally after having received various types of maternity care. DESIGN: The design was a cohort of Swedish women giving birth at full term. All together, 773 women and 782 newborns were followed using questionnaires, registry data, and medical chart notes. The information served as a basis for analyzing utilization of health care services during the first 28 days post-delivery. RESULTS: Of the women, 15% sought medical care and 1.7% were readmitted, whereas 17% of the newborns received medical care and 2.9% were readmitted. At 6 months, about half were exclusively being breastfed. There was no difference in need to seek health care or breastfeeding outcome owing to type of maternity care. CONCLUSION: Mothers with newborns sought care relatively frequently but rarely needed to be readmitted after discharge from the maternity care. The risk of readmission during the first month after childbirth was not greater for mothers and children who received care through the family suite or early discharge programs.     

Lack of antenatal care in far north Queensland

OBJECTIVE: To examine reasons for women not accessing antenatal care, and subsequent pregnancy outcomes for this group of women. DESIGN: Retrospective observational study between 1992 and 2001. SETTING: Large public provincial referral obstetric unit. SAMPLE: A total of 226 of 16 176 women (1.4%) who gave birth had not accessed antenatal care in the index pregnancy. RESULTS: The women who did not access antenatal care were more likely to be highly parous or young, indigenous, and users of alcohol than the women who did access antenatal care; women who lived in remote communities and women who significant medical conditions complicating their pregnancy were less likely to default on antenatal care. The women who did not access antenatal care had a higher incidence of preterm birth and post-partum haemorrhage; their babies were more likely to be of low birthweight, to be born with 5-min Apgar scores less than 5, and had a higher incidence of perinatal death. CONCLUSIONS: Lack of antenatal care is associated with a significant number of poor pregnancy outcomes, which are not explained by the basic epidemiological characteristics of women. As the women not accessing antenatal care tend to be from the most disadvantaged or marginalised groups in our society, a better understanding of their reasons for not accessing antenatal care is necessary so that care options can be provided which this high-risk group of women may find acceptable and use.     

Challenges of immediate newborn care in maternity units in Lagos, Nigeria: an observational study

Substandard newborn care has been identified as a major contributor to the estimated annual 4 million neonatal deaths and 1 million fresh stillbirths. Low-income countries, including Nigeria account for more than 95% of all cases. A cross-sectional comparative study utilising non-participant observation methods was used to study perinatal care at two maternity centres in Lagos, Nigeria. Data on 63 mother-baby pairs were included in the study. Two stillbirths and two early neonatal deaths occurred during the study period, equally divided between the two hospitals. The partograph, a crucial tool for monitoring progress of labour, was in use in 77.4% vs 50% of cases at the two centres. The only interventions utilised for the prevention of hypothermia were drying and covering newborns with towels. Hygiene routines were poor and caring procedures did not demonstrate adequate knowledge related to a newborn's health. An enabling environment and supportive supervision is urgently required.