Experiences and outcomes of women with bleeding in early pregnancy presenting to the Emergency Department: An integrative review

Exploring midwifery role and scope in acute early pregnancy care: a survey of midwives and midwifery students in Australia

BACKGROUND

The scope of practice of the contemporary midwife encompasses a range of sexual and reproductive healthcare, including care throughout pregnancy. Midwives are experts in pregnancy care, but many do not provide care for women with unexpected (acute) complications in early pregnancy (< 20 weeks) in Australia. Women experiencing acute pregnancy complications < 20 weeks usually attend an emergency department rather than a maternity unit. These settings do not typically employ midwives and may not meet women's need for timely and informed physical care and psychosocial support. A gap in evidence exists in relation to the role and scope of practice of the midwife in acute early pregnancy care provision in Australia.

METHODS

Midwives and midwifery students in Australia were purposively sampled and invited to complete an online cross-sectional survey exploring midwifery practice in acute early pregnancy care. Data were collected from July 1st to September 30th, 2024. Quantitative data were analysed using descriptive and inferential statistics. Free-text responses were analysed using inductive content analysis.

RESULTS

Responses from 294 midwives and 46 midwifery students (n = 340) were analysed. Participants recognised that midwives should provide acute care in early pregnancy, and many had knowledge, confidence or experience in this area. The most reported setting for acute early pregnancy care provision was the general emergency department; early pregnancy assessment service models were also common. Some settings prioritised the employment of registered nurses over midwives in acute early pregnancy services. Challenges to midwives providing acute early pregnancy care included inadequate clinical exposure as qualified midwives, and women being placed in non-maternity settings.

CONCLUSION

Participants supported midwives providing acute care in early pregnancy, confirming that midwives' professional scope should not be impacted by pregnancy gestation or outcome. However, current midwifery education programs may not be adequately preparing midwives to provide comprehensive care for women with acute early pregnancy complications. Those midwives who are providing care may not be fulfilling professional scope. Findings have utility in supporting policy, education and service review, and highlight further gaps in evidence for future research.

What assessment, intervention and diagnostics should women with early pregnancy bleeding receive in the emergency department and when? A scoping review and synthesis of evidence

BACKGROUND

Vaginal bleeding is a frequent complication in early pregnancy, care that women receive, or lack thereof, can have immediate and long-term consequences. There is a lack of cogent, synthesised evidence on the assessment, interventions, and diagnostics for the management of early pregnancy bleeding in the emergency department (ED). This paper reports the results of a scoping review that identified that examined the literature to clarify concepts and generate a synthesis of the evidence for the assessment, interventions, diagnostics and management of early pregnancy bleeding in the ED.

METHODS

Five databases were searched. Practice guidelines and statements were sourced from professional organisations, and online repositories. Three types of data were included: practice guidelines, reviews, and primary research. Data were extracted and collated, and findings were synthesised into a clinical guideline.

RESULTS

A total 122 (of 3602) papers from database searching, and six (of 46) practice guidelines were included. Seventy-seven publications reported on assessment including performing vital observations. Thirty-six reported on interventions including administration of analgesia, and 114 reported on diagnostics, which most (n = 93) recommended use of ultrasound. Few (12 %) of practice statements and guidelines recommended care not based in current evidence. The study yielded an evidence-based practice guideline to be used for initial management of early pregnancy bleeding.

CONCLUSIONS

The practice guideline generated by this examination and synthesis of the evidence offers comprehensive, evidence informed recommendations for the initial management of early pregnancy bleeding. Continued research and knowledge translation for initial management of early pregnancy bleeding is needed to reduce variation in emergency care and improve outcomes for women.

What proportion of women presenting to the emergency department with early pregnancy bleeding receive appropriate care?

OBJECTIVE

To determine the proportion of women presenting to EDs across a regional health district, with early pregnancy bleeding, who received appropriate care.

METHODS

Retrospective cohort review of linked data from five data sets: ED, pathology, radiology, costs and non-admitted/outpatient. Data collected from five EDs between January 2011 and December 2020, across one health district in NSW, Australia, with 150 000 annual ED presentations. Management received by women of reproductive age, with early pregnancy (<20 weeks gestation) bleeding was compared to seven indicators for recommended care. Indicators included blood tests, psychosocial support, administration of Rhesus D immunoglobulin and US. Indicators were determined by a systematic analysis of published primary research, expert consensus clinical practice guidelines and literature reviews on initial assessment, intervention and diagnostics for women with early pregnancy bleeding.

RESULTS

There was no evidence of almost one third of women (n = 3661, 29.4%) receiving any indicators and 54 (0.4%) received five or more indicators of appropriate care. Presentations to rural facility had the lowest number and proportion of indicators being performed (n = 603, 58.0% for no indicators). Cost increased with the number of indicators. Over the study period, the proportion of all indicators being performed increased, and indicator six - psychosocial support referral or care had the biggest growth (almost 500%).

CONCLUSIONS

Variation in care for women presenting with early pregnancy bleeding to ED was identified. There is an evidence-practice gap and need for inquiry into barriers and facilitators to prescribed clinical practice for this population.

Midwives' and registered nurses' role and scope of practice in acute early pregnancy care services: a scoping review

OBJECTIVE

The objective of this scoping review was to investigate and describe what is reported on the role and scope of practice of midwives and registered nurses providing care for women with pregnancy complications prior to 20 weeks' gestation in acute clinical settings in Australia.

INTRODUCTION

In many high-income countries, women experiencing unexpected complications in early pregnancy attend an acute care service, such as an emergency department, rather than a maternity or obstetric unit. This service structure can impact the care women receive and determine who provides it. Women and their partners, who are often experiencing emotional distress, have reported difficult experiences when accessing acute services, particularly emergency departments, which are not traditionally staffed by midwives. The role and scope of practice of both midwives and registered nurses providing acute early pregnancy care in most high-income countries, including Australia, is poorly reported. Documenting this area of practice is an important first step in facilitating ongoing research in this important aspect of pregnancy care.

INCLUSION CRITERIA

Published and gray literature that described the role and scope of practice of midwives and/or registered nurses providing care in acute early pregnancy settings in Australia were considered for this review.

METHODS

A scoping review of the literature was conducted following JBI methodological guidance and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A 3-step search strategy was conducted to explore evidence from databases and search engines, gray literature sources, and selected reference lists. The search was limited to sources published from 2005 until October 2023. The databases searched included MEDLINE (Ovid), MIDIRS (Ovid), JBI Evidence-based Practice Database (Ovid), CINAHL Ultimate (EBSCOhost), ProQuest Central, Web of Science Core Collection, Scopus, and Cochrane Library. Google and Google Scholar were also used to identify published studies. After screening, data were extracted from records selected for the final review, mapped, and analyzed using content analysis.

RESULTS

A total of 23 sources were selected for inclusion in the review, and these included primary research studies, conference abstracts, and gray literature, such as clinical guidance documents, academic theses, and websites, from January 2008 to October 2023. The most common setting for care provision was the emergency department. Midwives' and registered nurses' role and scope of practice in acute early pregnancy care in Australia can be categorized into 4 areas: physical care, psychosocial support, care coordination, and communication. Women's access to midwifery care at this time in pregnancy appears to be limited. Registered nurses, usually employed in emergency departments, have the most prominent role and scope in the provision of care for women with acute early pregnancy complications. Descriptions of midwives' practice focus more on psychosocial support and follow-up care, particularly in early pregnancy assessment service models.

CONCLUSIONS

This review highlights the inconsistency in midwives' and registered nurses' role and scope in acute early pregnancy in Australia, a finding which is relevant to other international settings. Both professions could further fulfill role and scope capacity in the provision of supportive, individualized, and timely care for women and families accessing a range of acute early pregnancy services. Emergency departments are the usual practice domain of registered nurses who may be limited in terms of the scope of care they can provide to women with early pregnancy complications. Leaders of the midwifery profession should conduct further research into innovative service models that embed a role for midwives in all settings that provide care for pregnant women, regardless of stage of pregnancy.

REVIEW REGISTRATION

Open Science Framework https://osf.io/7zchu/.

Midwives' and registered nurses' role and scope of practice in acute early pregnancy care settings in Australia: A qualitative descriptive study

PROBLEM

There is little documented evidence regarding the practice of midwives providing care for women with acute concerns in early pregnancy (< 20 weeks) in Australia.

BACKGROUND

Women can experience unexpected complications at any gestation of pregnancy and may seek acute care in an emergency or gynaecology service, usually staffed by registered nurses (RNs). They may not receive care from specialised pregnancy clinicians, including midwives. The role and scope of practice of midwives working in acute early pregnancy settings in Australia has not been previously reported. This study provides an opportunity to document practice in an area of pregnancy care not often visible within maternity services in Australia.

RESEARCH AIM

To describe midwives' and RNs perceptions, perspectives and experiences of role and scope of practice in acute early pregnancy care provision in Australia.

METHODS

A qualitative descriptive approach was adopted. Midwives and RNs with acute early pregnancy knowledge and experience were recruited. Semi-structured interviews were conducted, and data analysed using inductive thematic analysis.

FINDINGS

Fifteen participants were interviewed. Three themes were constructed from interview data: Personal and Professional Influences; Being There for Women; The Impact of Setting.

DISCUSSION

Findings reinforce the lack of clarity around how midwives' scope is enabled in traditional acute early pregnancy care. Setting of care has influenced practice and seen a barrier for midwives who don't hold nursing registration from fulfilling professional scope. Results provide novel benchmarking evidence regarding a largely hidden area of midwifery, signposting areas for reform within education, policy and health service sectors.

Presentation trends, characteristics and outcomes for women with early pregnancy bleeding in the emergency department: A 10-year data linkage study

BACKGROUND

Women present to the emergency department (ED) with pregnancy complications including bleeding. They seek investigations, treatment and clear discharge and referral pathways.

AIMS

The aim was to identify trends, characteristics, ED care and discharge pathways for women who present to the ED with early pregnancy bleeding.

METHODS

Retrospective data (from 2011 to 2020) were extracted from a regional health district's databank. Data were processed, and deterministic linking was used to produce a final data set. Descriptive statistics were used to identify trends and characteristics. Linear and logistic regression models were used to identify factors that influence health service use, outcomes and discharge pathways.

RESULTS

Over the 10 years, there have been almost 15 000 presentations to the ED for early pregnancy bleeding, from approximately 10 000 women, 0.97% of all ED presentations. The frequency of presentations increased by 19.6% over the study period. The average age of women who presented to the ED was 29.1 years, which increased from 28.5 years (2011) to 29.3 (2020). The median length of stay was less than 4 h, and most women were treated and discharged from the ED. One-third of presentations received neither ultrasound nor pathology, but health service costs increased by 330% from 2014 to 2020.

CONCLUSIONS

Maternal age is increasing, as is the frequency of ED presentations for early pregnancy bleeding, and both factors increase demands on the ED. Findings from this study may inform strategies to improve current care models and improve quality and safety practices within the ED.

Midwives' and registered nurses' role and scope of practice in acute early pregnancy care services in Australia: a scoping review protocol

OBJECTIVE

The objective of this review is to review and synthesize what is documented on the role and scope of practice of midwives and registered nurses working in acute early pregnancy care settings in Australia.

INTRODUCTION

Women experiencing complications before 20 weeks of pregnancy may need to attend an acute care service, often a hospital emergency department. Midwives and registered nurses provide care for women with early pregnancy complications, and it is important that their role and scope of practice is documented. This review will explore the literature relating to acute early pregnancy care in Australia to better understand how midwives' and registered nurses' roles and scope are currently described in this setting.

INCLUSION CRITERIA

Any literature that explores the role and scope of practice of midwives and registered nurses who care for women who present to acute care services in Australia with early pregnancy complications will be considered for inclusion in the review.

METHODS

A 3-step review process will involve a preliminary search of MEDLINE and ProQuest, followed by a more detailed search of a larger selection of databases, using identified keywords and phrases from the initial search. Reference lists of retrieved literature will then be examined for relevant citations. Literature in English will be considered, including relevant gray literature. Search results will be imported into reference and review support software. Data that align with the inclusion criteria will be organized into tabulated and narrative formats for presentation.

DETAILS OF THIS REVIEW PROJECT ARE AVAILABLE AT

Open Science Framework https://osf.io/5bnqz.