Nursing Protocols for Antepartum Home Care

Home care for women experiencing high-risk complications of pregnancy is a growing phenomenon. Home-care protocols for basic antenatal visits and the common conditions managed at home, such as preterm labor, premature rupture of membranes, bleeding, pregnancy-induced hypertension, chronic hypertension, and diabetes during pregnancy, are presented. Knowledge of protocols guiding home care of the antepartum client enhances communication, collaboration, and coordination and ultimately fosters dialogue, which can improve the quality of care for women.     

High-risk Infants The Need for Nursing Follow-up

The goal of perinatal care can no longer focus only on the medical management of mother and infant, but instead must take a more global approach and focus on the entire family. One aspect of family care is to provide comprehensive nursing follow-up to the high-risk family at the time of the mother's and infant's discharge. To meet this need, a program was developed to educate all interested community nurses to the specific needs of the high-risk family. Evaluation indicates that the program helped nurses to provide consistent comprehensive care to these families, who were very grateful for home visits by a community nurse.     

远程胎儿心率监护网络在高危妊娠中的临床应用

目的　探讨远程胎儿心率监护网络作为高危妊娠围生期孕妇家庭自我监护方法的临床应用价值。方法　 2 0 0 1年 1月至 2 0 0 4年 7月深圳市第二人民医院选择 1 36例高危妊娠孕妇 ,采用远程胎儿心率监护网络进行无负荷试验 (NST)监测 (研究组 ) ,选择同期进行常规胎儿心率监护的高危孕妇 1 4 0例作为对照 (对照组 ) ,分析两组胎儿心率监护的监测结果和围生儿结局。结果　研究组NST异常检出率 (36 6 %)较对照组 (2 8 3%)明显增高 (P <0 0 5 )。研究组NST异常图形为变异减速、基线变异减少或胎儿心率 (FHR)过缓 ,与对照组比较 ,差异均有显著性 (P <0 0 5 )。研究组新生儿窒息和早产儿的发生率低于对照组 (P <0 0 5 )。两组剖宫产率的差异无显著性 (P >0 0 5 )。结论　应用远程胎儿心率监护网络进行高危妊娠的监测 ,可改善围生儿预后 ,是高危妊娠孕妇自我监护的新选择。     

远程胎心监护临床应用价值评估

远程胎心监护技术是一种开放式分布的监护系统，是院内胎心监护的补充，围产期保健的院外延伸；丰富了家庭自我监护的内涵，是胎儿安全的有力保障；为高危妊娠和伴有脐带因素胎儿的孕期管理开辟了一条有效、实用、可行的新途径。科学管理，加强质控乃是远程胎心监护开展与推广的前提。     

High-risk pregnancy: postpartum rehospitalization.

OBJECTIVE: Examine frequency, timing, and reasons for maternal postpartum rehospitalizations and acute care visits 1 year postpartum after a high-risk pregnancy. STUDY DESIGN: Secondary analysis of data collected during a randomized clinical trial of advanced practice nurses gives transitional care for women with high-risk pregnancies. The 171 women were primarily African American, never married, Medicaid eligible, diagnosed with pregestational diabetes (20), gestational diabetes (23), either diagnosed (48) or at risk (44) for preterm labor, and chronic hypertension (36). RESULTS: Of the total rehospitalizations (17%) and acute care visits (32%), over one third occurred in the first 8 weeks postpartum. Chronic hypertensives and gestational diabetics had the highest rate of rehospitalization and proportion of acute care visits. Six women were rehospitalized for subsequent pregnancies. CONCLUSION: Women with high-risk pregnancies have continued high health care resource use over the first postpartum year demonstrating the need for more intensive patient education and follow-up to improve outcomes and reduce resource use.     

Maternal self-administered fetal heart rate monitoring and transmission from home in high-risk pregnancies.

OBJECTIVES: To evaluate the feasibility of high-risk pregnancy surveillance by patient-directed fetal heart rate monitoring and transmission, and to assess patient satisfaction with this technology. METHODS: Thirty-six women with high-risk pregnancies performed daily non-stress tests at home and transmitted the data to our perinatal care center by telephone. At each transmission, patients were asked by a physician about perceived fetal movements and uterine contractions and given the results. If the tracing was unsatisfactory, further evaluation was performed. In addition, patients completed a questionnaire on quality of life and anxiety state before and after the study. RESULTS: All patients were able to perform the tests and transmissions. The quality of recorded data was significantly correlated with maternal body mass index, but not with gestational age at the time of monitoring or birth weight. Thirty-nine of the total 562 tracings (6.9%) were inconclusive or non-reassuring. After repeated testing, 32 of them (82%) were considered normal, and seven patients (18%) were referred for additional in-hospital evaluation. Of this group, four were discharged for further surveillance with routine home monitoring and the remaining three were hospitalized for continued evaluation. There were no significant immediate adverse maternal or neonatal outcomes as a result of the monitoring. Patient satisfaction was high. CONCLUSIONS: Daily home FHR monitoring in high-risk patients is safe and feasible at all gestational ages, based on this initial pilot evaluation. It is easily and reliably performed and accepted by patients with a high level of satisfaction.     

远程胎儿监护在高危妊娠中的临床应用

目的:探讨远程胎儿监护在高危妊娠中的临床应用。方法:2004年3月至2005年6月在产科门诊诊断为高危妊娠的孕妇57例作为研究组,并于孕35周以后用远程胎儿监护终端部分(以远程胎儿监护结合胎动计数进行家庭自我监护),随机选择同期高危妊娠孕妇58例,在家中以胎动计数结合门诊常规NST检查作自我监护,作为对照组,比较两组的NST异常和围生儿不良预后发生率。结果:研究组57例孕妇中,NST异常21例,检出率为37%,对照组58例,NST异常11例,检出率为19%,两组比较差异有显著性(P<0.05),对照组58例中,发生围生儿不良预后27例,发生率为47%,研究组57例中发生围生儿不良预后12例,发生率为21%,两组比较差异有显著性(P<0.05)。结论:应用远程胎儿监护对高危妊娠的监测,可降低新生儿窒息等围生儿预后不良的发生率,为高危妊娠孕妇的自我监护和管理开辟了一条有效、实用、可行的途径。     

HOME-BASED SERVICES BY NURSE-MIDWIVES

This article presents prospective data from Phase II of Nurse-Midwifery Care to Vulnerable Populations in the United States, about home-based health care, including home birth, provided to women and infants by CNMs and the type of practice in which these services are provided. Forty-one certified nurse-midwives collected data on 1,739 client visits, of which 234 occurred in the home. The results indicate that the majority of home visits occur within a practice setting that includes more traditional modes of service and that a proportion of women choose home as the place for health care.     

Home-based services by nurse-midwives: Sample data from phase II of nurse-midwifery care to vulnerable populations in the United States

This article presents prospective data from Phase II of Nurse-Midwifery Care to Vulnerable Populations in the United States, about home-based health care, including home birth, provided to women and infants by CNMs and the type of practice in which these services are provided. Forty-one certified nurse-midwives collected data on 1,739 client visits, of which 234 occurred in the home. The results indicate that the majority of home visits occur within a practice setting that includes more traditional modes of service and that a proportion of women choose home as the place for health care.     

Home Phototherapy for Newborn Jaundice

Home phototherapy programs for otherwise healthy term newborns are becoming popular because they do not necessitate the separation of the newborn from the family and are less costly than the same care delivered in hospital. Home phototherapy may operate under the auspices of a hospital or affiliated home health care agency, a private pediatric practice, or an independent nurse practice. Important elements of all programs include mechanisms for referral, criteria for selection of families, and monitoring the use of the bililights and the baby's progress during home visits by nurses. Programs we surveyed have been well received by parents. Caregivers report few problems or complications.     

Home uterine activity monitoring in France: a randomized, controlled trial.

OBJECTIVES: We assessed the effectiveness of ambulatory tocodynamometry in reducing the preterm delivery rate in women at risk of preterm delivery such as women with risk factors and women previously hospitalized and discharged. STUDY DESIGN: In four public maternity units these women were randomly allocated to two groups: 84 had home uterine activity monitoring and daily midwife contact and 84 were given the standard care for high-risk women, which generally includes home visits by community midwives. RESULTS: The proportion of deliveries before 37 weeks' gestation was slightly higher in the monitored group than in the control group (32% vs 22%). The corresponding odds ratio was 1.7 (95% confidence interval: 0.9 to 3.5). CONCLUSION: Although the sample was small, these results suggest that home uterine activity monitoring was probably not beneficial to the population studied, or at least that any benefit would have been too small to justify extending this monitoring in this high-risk population.     

The impact of prenatal care in the United States on preterm births in the presence and absence of antenatal high-risk conditions

OBJECTIVE: This study was undertaken to determine the association between prenatal care in the United States and preterm birth rate in the presence, as well as absence, of high-risk pregnancy conditions for African American and white women. STUDY DESIGN: Data were derived from the natality data set for the years 1995 to 1998 provided by the National Center for Health Statistics. Analyses were restricted to singleton live births that occurred at >/=20 weeks' gestation. Multiple births, fetal deaths, congenital malformations, chromosomal abnormalities, missing data on gestational age, and birth weight less than 500 g were excluded. Multivariable logistic regression analyses were used to adjust for the presence or absence of various antenatal high-risk conditions, maternal age, gravidity, marital status, smoking, alcohol, and education. Prenatal care was considered present if there was one or more prenatal visits. Preterm delivery was defined as delivery at less than 37 completed weeks of gestation. RESULTS: For 14,071,757 births analyzed, 1,348,643 (9.6%) resulted in preterm birth. Preterm birth rates were higher for African American women than white women in the presence (15.1% vs 8.3%) and absence (34.9% vs 21.9%) of prenatal care. The absence of prenatal care increased the relative risk for preterm birth 2.8-fold in both African American and white women. There was an inverse dose-response relationship between the number of prenatal visits and the gestational age at delivery both among African American and white women. Lack of prenatal care was associated with increased preterm birth rates to a similar degree in the presence of pregnancy complications for both African American and white women, ranging from 1.6-fold to 5.5-fold for the various antenatal high-risk conditions. CONCLUSION: In the United States, prenatal care is associated with fewer preterm births in the presence, as well as absence of high-risk conditions for both African American and white women. Strategies to increase prenatal care participation may decrease preterm birth rates.     

Absence of fetal movements and normal infants

Pregnant women feel movements from about the fifth month of pregnancy. In cases of high-risk pregnancy daily recording of fetal movements is useful in monitoring fetal well-being. Complete cessation of fetal movements points to a severely distressed fetus and impending death. We report here five women in whom failure to experience fetal movements was present from the beginning of pregnancy, or occurred after fetal movements had been felt for several weeks during the pregnancy. All the women delivered normal infants with high Apgar score.     

A Collaborative Framework for Managing Pregnancy Loss in the Emergency Department

The purpose of this article is to examine how nurses can improve comprehensive care for women who suffer an early pregnancy loss in the emergency department and highlight the integral role of obstetric and emergency department nurses within a new holistic framework of collaborative care. These nurses are integral in the proposed collaborative "fetal loss framework," which provides an innovative approach for holistic care for this population.     

Some characteristics of antenatal care in 13 European countries

This study compares the organization of antenatal care in 13 European countries having a fetal and infant mortality rate below 20 per 1000. The countries differ in the number of prenatal visits, the role performed by midwives and the use of home care. It shows that there is no single model of antenatal care among countries having similar fetal and infant mortality.     

Time of Pregnancy Recognition and Prenatal Care Use: A Population‐based Study in the United States

Background: A woman who does not recognize her pregnancy early may not initiate prenatal care early. This study examined the relationship between the time of pregnancy recognition and the time of initiation of prenatal care, and the number of prenatal visits among women of childbearing age. Methods: This study analyzed the Pregnancy Risk Assessment and Monitoring System (PRAMS) data for the United States. The analysis sample was representative of resident women of childbearing age in 29 U.S. states who had live births within 2 to 6 months before being contacted. The data were weighed to reflect the complex survey design of the PRAMS, and binary and multinomial logistic regressions were used for the analyses. Results: Most (92.5%) of the 136,373 women in the study had recognized their pregnancy by 12 weeks of gestation, and 80 percent initiated prenatal care within the first trimester. Early pregnancy recognition was associated with significantly increased odds of initiating prenatal care early (OR = 6.05, p < 0.01), after controlling for sociodemographic and prior birth outcome data, and was also associated with lower odds of having fewer than the recommended number of prenatal visits and higher odds of having more than the recommended prenatal visits (OR: <11 visits = 0.71 and >15 visits = 1.17, p < 0.01). Conclusions: Early pregnancy recognition was associated with improved timing and number of prenatal care visits. Promotion of early pregnancy recognition could be a means of improving birth outcomes by encouraging and empowering women to access prenatal care at a critical point in fetal development. (BIRTH 37:1 March 2010)     

Some characteristics of antenatal care in 13 European countries

Summary. This study compares the organization of antenatal care in 13 European countries having a fetal and infant mortality rate below 20 per 1000. The countries differ in the number of prenatal visits, the role performed by midwives and the use of home care. It shows that there is no single model of antenatal care among countries having similar fetal and infant mortality.     

Retrofitting technology to nursing: the case of electronic fetal monitoring

OBJECTIVES: To describe how nurses put electronic fetal monitoring to use in the 1960s and 1970s and the dilemmas this caused. DESIGN: Social history. RESULTS: Nurses used electronic fetal monitoring to improve the watchful and comfort care of childbearing women, and they saw it as validating nursing. They retrofitted, or worked to reconcile machine monitoring with natural, prepared, and participative childbirth, and with attentive and embodied nursing. CONCLUSION: Electronic fetal monitoring was another in a long line of technological innovations that fell to nurses to put into use and to make work. The remarkably rapid way electronic fetal monitoring became routine in the United States depended, in large part, on the articulation work of nurses. However, like all such work, what nurses did to make electronic fetal monitoring work for patients, physicians, hospitals, and manufacturers was largely invisible. Retrofitting efforts often entail unrecognized innovation and risks for nursing.     

Perinatal malpractice. Risks and prevention

An analysis of 25 perinatal malpractice cases filed in Wisconsin between 1978 and 1984 clearly revealed that the unfavorable outcomes were preventable and caused by professional negligence. Each case was settled or adjudicated in favor of the plaintiff, and the awards totaled $25.1 million. Although cases with a total recovery of over $1 million are relatively infrequent, they are not so rare as to be considered extra-ordinary occurrences. Fifty-six percent of physicians involved failed to recognize a high-risk pregnancy or fetal distress, while 44% failed to render proper care. The most common errors involved inadequate fetal monitoring, the injudicious use of oxytocin and the failure to recognize a high-risk pregnancy, such as prematurity or postterm or multiple gestation. The purpose of this study was to examine the medicolegal issues operating in such cases in order to develop guidelines for reducing professional negligence, thereby preventing injury to women and their newborns.