Improving the accuracy of fetal foot length to confirm gestational duration

OBJECTIVE: To establish normative fetal foot length ranges using last menstrual period (LMP) and ultrasound dating by biparietal diameter and to examine variations in these ranges by ethnicity. METHODS: A consecutive series of 1,099 eligible subjects receiving abortions had fetal foot lengths measured directly. Models of fetal foot length were developed by using assessment of gestational duration by LMP alone, ultrasonography alone, and "best estimate" (LMP confirmed by ultrasonography). RESULTS: The full sample model using ultrasound dating (n = 1,099) yielded the following equation: foot length = -30.3 + days of gestation x 0.458 (R(2) of 0.92). Regression by LMP-determined gestational duration by using the "best estimate" sample (n = 491) provided an almost identical equation (foot length = -29.8 + days of gestation x 0.45) and a similar R(2) value of 0.87, although the standard errors were larger. Gestational duration by ultrasonography alone produced a better model fit than duration by LMP alone. Regressions by ethnicity were not significantly different compared with the simple regression, regardless of method used to determine gestational duration. CONCLUSION: A reconsideration of fetal foot length measurements to confirm gestational duration is important. More accurate tables of these measurements allow for greater precision in correlating gestational duration and foot length. Fetal foot length tables using ultrasonographically confirmed gestational duration and current statistical standards should replace tables currently used. Biparietal diameter as a single measurement provides adequate estimation of gestational duration in the second trimester for pregnancy termination, proving more reliable than LMP dating. LEVEL OF EVIDENCE: II-2.     

Abortion attitudes of pregnant women in prenatal care

OBJECTIVE: This study was undertaken to describe abortion attitudes in a diverse cohort of pregnant women enrolled in prenatal care. STUDY DESIGN: A cross-sectional interview study of 1082 demographically diverse gravid women enrolled in prenatal care at less than 20 weeks' gestation was performed. RESULTS: Most participants (92%) supported abortion availability. Half (50%) who were willing to consider an abortion would do so only in the first trimester. Among the gravid women willing to consider an abortion in the first or second trimester, 84% would do so after rape/incest or if their life was endangered and 76% would if their fetus had Down syndrome. Gravid women considering abortion were more likely to be white, older, have had a previous abortion, and to express distrust in the health care system. Women who would not consider abortion were more likely to be multiparous, married/living with partner, and to express greater faith and fatalism about their pregnancy outcome. CONCLUSION: Although most pregnant women enrolled in prenatal care support abortion availability, about half would only consider a first-trimester procedure. These findings underscore the need for early prenatal genetic counseling, screening, and testing.     

A meta-synthesis of women’s experiences of online forums for maternal mental illness and stigma

Archives of Women's Mental Health - Perinatal mental illness affects 15% of women; however, only half of these women access treatment. Some women with untreated perinatal mental illness may...     

The implementation of nursing diagnoses. The Iowa Veterans Home experience

This article has reviewed the process of implementing nursing diagnoses in one long-term care agency. Nursing diagnoses improved nursing process skills, made problem identification more accurate, and aided the identification of nursing interventions and desired outcomes. Nursing diagnoses have become the organizing framework for quality assurance, staff development, specialization and consultation, and computer applications. The presence of a professional model of nursing practice facilitated the use of nursing diagnoses. Prior to implementing nursing diagnoses, IVH nurses had defined the scope of nursing practice and formed a committee structure for decision-making by all RNs. The structure included mechanisms for collective and individual accountability. All nurses participated in the decision to use nursing diagnoses in their practice. Each nurse had the opportunity to influence the process of change. The process of implementing nursing diagnoses at IVH continues. Nurses recognize the need to establish the validity of each diagnostic statement. Skill with the diagnostic process is expected to improve. Nurses also recognize the need to test interventions for specific diagnoses. The standard nomenclature will continue to be used for the improvement of nursing practice and for nursing department programming. The use of nursing diagnoses is the basis of the continued development of a professional model of nursing practice.     

Safety of Aspiration Abortion Performed by Nurse Practitioners,Certified Nurse Midwives,and Physician Assistants Under a California Legal Waiver

Objectives. We examined the impact on patient safety if nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) were permitted to provide aspiration abortions in California.Methods. In a prospective, observational study, we evaluated the outcomes of 11 487 early aspiration abortions completed by physicians (n = 5812) and newly trained NPs, CNMs, and PAs (n = 5675) from 4 Planned Parenthood affiliates and Kaiser Permanente of Northern California, by using a noninferiority design with a predetermined acceptable risk difference of 2%. All complications up to 4 weeks after the abortion were included.Results. Of the 11 487 aspiration abortions analyzed, 1.3% (n = 152) resulted in a complication: 1.8% for NP-, CNM-, and PA-performed aspirations and 0.9% for physician-performed aspirations. The unadjusted risk difference for total complications between NP–CNM–PA and physician groups was 0.87 (95% confidence interval [CI] = 0.45, 1.29) and 0.83 (95% CI = 0.33, 1.33) in a propensity score–matched sample.Conclusions. Abortion complications were clinically equivalent between newly trained NPs, CNMs, and PAs and physicians, supporting the adoption of policies to allow these providers to perform early aspirations to expand access to abortion care.Increased access to early abortion is a pressing public health need. By 2005, the number of abortion care facilities in the United States had decreased 38% from its peak in 1982.1 Although the number has since remained stable, the proportion of US counties with no facility remains high at 87%; more than one third of women aged 15 to 44 years live in these counties.2 Additionally, a large proportion of US facilities are hospitals that perform abortions only in cases of serious medical and fetal indications or facilities that offer medical abortions only up to 9 weeks of pregnancy.2Many women face difficulties finding a facility, resulting in delayed care.3 Increasing access is critical because abortions at later gestations are associated with a higher risk of complications4 and higher costs.2 Research has also found that many women would prefer to obtain their abortions earlier5 Finally, traditionally underserved populations experience the greatest barriers to abortion care, resulting in higher rates of procedures after the first trimester.6,7In California, more than half of the 58 counties lack a facility that provides 400 or more abortions (R. K. Jones, PhD, Guttmacher Institute, written communication, November 2011). Low-income and minority women are most likely to be served by public health departments or community health centers,8 most of which do not provide abortions. These women are also more likely to be cared for by nurse practitioners (NPs) and physician assistants (PAs) than by obstetricians and gynecologists.9One potential solution to improve access is to increase the number and types of health care professionals who offer early abortion care.10–12 Increased emphasis has been placed on task sharing to better meet women’s health needs in the context of health care workforce shortages.13 In the United States, health professions are regulated through a patchwork of state regulations14,15 that determine who can perform abortions, a power reaffirmed by several US Supreme Court decisions.16–18 Currently, nonphysician clinicians can perform aspiration abortions legally in only 4 states—Montana, Oregon, New Hampshire, and Vermont. Two additional states (Kansas and West Virginia) do not limit the performance of abortions to physicians, but nonphysician clinicians have never tried to provide abortion care. Of the remaining 44 states (Figure 1), some allow nonphysician clinicians to perform medical (but not aspiration) abortions under decisions by attorneys general or health departments, and 1 state—California—passed statutory authority for that care. As part of a larger effort to limit abortion access, several states have recently promulgated laws that specifically prohibit nonphysician clinicians from performing abortions.19 For example, a 2009 Arizona law (HB 2564 and SB 1175) that precluded NPs from providing abortions resulted in the discontinuation of abortion care at several facilities that had previously been staffed exclusively by NPs.20Open in a separate windowFIGURE 1—Landscape of health professional regulation of abortion provision in the United States.Note. CNM = certified nurse midwife; NP = nurse practitioner; PA = physician assistant.Limited clinical evidence is available to inform policymakers about whether physician-only legal restrictions on abortion are evidence-based.21–24 Our study was designed to provide this evidence to policymakers; it answers the question “What would be the impact on patient safety if NPs, PAs, and certified nurse midwives (CNMs) were permitted to provide aspiration abortions in California?” (We use the term aspiration abortion to refer to what is commonly called surgical abortion because the technique does not meet the technical definition of surgery.25) We used a noninferiority design to compare the incidence of abortion-related complications between groups because we anticipated a slightly higher number of complications among newly trained NPs, CNMs, and PAs than among the experienced physicians.