Intrapartum Fetal Intensive Care: 2-Year Experience

Summary: Reappraisal of 2,279 electronically-monitored labours in the fetal intensive care unit enabled the formation of a policy for the management of high risk pregnancies in labour. In the presence of meconium, major cardiotocographic heart rate abnormalities were as predictive of perinatal outcome as fetal acidosis (pH < 7.25). However, fetal scalp pH estimation did significantly reduce the incidence of Caesarean section for fetal distress. The perinatal mortality in the study was 1.32 per 1,000 births.     

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.     

Assessing Women's Preferences for Intrapartum Care

Background: Recent government reports have recommended involving consumers in the planning of health services. Although satisfaction surveys have traditionally been used, they have several limitations. This paper describes a relatively new method of eliciting consumer preferences that allows respondents (women) to indicate the importance that they attribute to specific aspects of a service. The aim was to explore the feasibility of using a discrete choice experiment to assess the importance to women of different aspects of intrapartum care. Methods: In this pilot study of 301 women at low obstetric risk, data were collected using an anonymous self‐complete questionnaire given to each participant by the midwife at the booking visit. Results: The results of the regression model suggest that respondents prefer maternity units that offer greater continuity of caregiver, more methods of pain relief, continuous fetal heart rate monitoring, a homely appearance, routine involvement of medical staff, and greater involvement for the woman in the decision‐making process. Although all attributes were important to women, they were not all of equal importance. For example, if continuity of caregiver were achieved at the expense of decreasing the availability of pain relief then women would be worse off. Conclusions: The discrete choice experiment appears to be a useful tool in assessing the strength of women's preferences for different aspects of maternity care. Future research should include a qualitative approach to explore in greater depth the processes involved in shaping women's preferences.     

Part 2. Antepartum and Intrapartum Care

The spread of human immunodeficiency virus (HIV) disease among childbearing women presents a unique nursing challenge in the delivery of specialized antepartum and intrapartum care. The nurse must be competent in the delivery of psychosocial and physical care to these women, as well as assume a pivotal role as a member of the multidisciplinary health-care team. Aspects of care, from the diagnosis of pregnancy through delivery of the neonate, that are unique to women with HIV disease are described.     

Using Evidence-Based Practice to Improve Intrapartum Care

The Cochrane Data Base (www.cochranelibrary. com/clibhome/clib.htm, retrieved February 23, 2001), a comprehensive international review of current medical and obstetric practices, demonstrates that birth outcomes improve with one-to-one labor support but not necessarily with continuous fetal monitoring. Because of a cultural bias toward technology, however, few extrinsic rewards exist for nurses who provide individualized labor support. Clinical scholarship in the obstetric setting is one way to begin changing ritualized practices, incorporating evidence-based practice, and improving nursing care.     

Intrapartum Care for Women With Multiple Pregnancy

Intrapartum management of multiple pregnancy presents many challenges for obstetric nurses. Optimal care often is complicated by prematurity, low and very low birth weights, and the unique circumstances of the delivery of multiple neonates. Higher perinatal mortality for multiple pregnancies continues to complicate delivery outcome. Nurses need special knowledge and skills to provide care for women with a variety of high-risk conditions in rapidly changing situations.     

Intrapartum Care of a Woman With Aortic Aneurysms

Advances in technology and complex care have enabled women with various health problems to become and remain pregnant. Consequently, health-care practitioners are seeing an increasing number of pregnant women who have aortic aneurysms. This case study describes the culturally sensitive intrapartum care of a Middle Eastern woman with ascending and descending aortic aneurysms.     

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.     

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.