Nursing Support During Latent Phase Labor: A Scoping Review

Quality-Improvement Strategies for Safe Reduction of Primary Cesarean Birth: ACOG Committee Statement No. 17

The nulliparous, term, singleton, vertex (NTSV) cesarean birth rate is a metric that may be used to evaluate obstetric care and compare performance across similar hospitals and regions. Safe reduction of primary cesarean birth prevents the need for future cesarean births and associated maternal morbidity risk. Quality-improvement methodologies such as optimizing culture of care; practice environment; data collection and monitoring, including monitoring of data by race and ethnicity; and proactive management and planning for known and unanticipated drivers of cesarean birth may safely reduce NTSV cesarean birth rates. Obstetrician-gynecologists should engage with patients in informed decision making, informed consent, and birth preference conversations, particularly related to induction of labor and cesarean birth, to support equitable and respectful obstetric care and outcomes related to NTSV cesarean birth.

Elective Induction of Labor May Have Negative Effects at the Hospital Level

Labor induction increased in the United States after the publication of A Randomized Trial of Induction Versus Expectant Management (ARRIVE) in 2018. During this trial, investigators found that elective induction at 39 weeks in low-risk nulliparous women led to similar perinatal outcomes when compared to expectant management. However, other researchers have since linked rising labor induction rates to worse hospital- and population-level outcomes. It is possible that elective induction of labor has a neutral effect on patients who are induced while at the same time lessening hospital capacity to care for other maternity patients, which leads to a negative effect on patient outcomes overall. During a trial, this represents a form of negative spillover, in which an intervention indirectly harms the comparison group and leads to overestimation of intervention benefit. Although further research is needed, evidence from ARRIVE and subsequent studies provides preliminary support for this possibility.

Shared Decision Making in Perinatal Care

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Reliability and Validity of a Perinatal Shared Decision-Making Measure: The Childbirth Options, Information, and Person-Centered Explanation

OBJECTIVE

To develop and test the psychometric properties of a shared decision-making tool: Childbirth Options, Information, and Person-Centered Explanation (CHOICEs).

DESIGN

Multiphase instrument development study beginning with item development through a cross-sectional postpartum survey.

SETTING

The cross-sectional postpartum survey was distributed online through convenience and snowball sampling methods.

METHODS

We developed instrument items through an iterative process with key stakeholders. We evaluated reliability based on internal consistency and differential item functioning analysis. We evaluated validity on evidence of construct validity. We used criterion-related item mapping to evaluate whether the measure addressed the full spectrum of shared decision making related to maternity care.

RESULTS

Surveys were completed by 1,171 participants. A Cronbach's αcoefficient of .99 supported internal consistency reliability. Infit and outfit statistics that ranged from 0.92 to 1.55 supported item fit. Differential item functioning analysis showed that CHOICEs scores were invariant between different demographic groups. Significant positive correlations between scores on CHOICEs and the Mothers on Respect index (r = 0.75, p = .01) and the Mothers Autonomy in Decision-Making scale (r = 0.75, p = .01) supported criterion-related validity. Item mapping suggested more items were needed to capture the full spectrum of shared decision making.

CONCLUSION

We recommend using CHOICEs to evaluate shared decision making in maternity care for research and quality improvement projects.

Content validity of the nursing diagnosis powerlessness in women during natural childbirth

OBJECTIVE

To validate the content of the nursing diagnosis powerlessness in women during natural childbirth.

METHOD

A nursing diagnosis content validation, in which 29 experts analyzed the definition of powerlessness and assessed the relevance of related factors, populations at risk, associated conditions and defining characteristics. These elements were considered relevant when the Content Validity Index was greater than or equal to 0.9.

RESULTS

Experts considered the definition resulting from the concept analysis more appropriate for the diagnosis under study. Regarding the assessment of diagnostic elements, 10 related factors, two populations at risk, three associated conditions and 10 defining characteristics were considered relevant.

CONCLUSION

The new definition for powerlessness and 25 elements have been validated by experts. These can support the operationalization of the Nursing Process for parturient women.

Improving Nurse Self-Efficacy and Increasing Continuous Labor Support With the Promoting Comfort in Labor Safety Bundle

OBJECTIVE

To increase nurse self-efficacy and the use of continuous labor support and to reduce the rate of primary cesareans among nulliparous women with low-risk pregnancies by implementing the Promoting Comfort in Labor safety bundle.

DESIGN

A quality improvement project with a pre-post practice implementation design. This practice change was part of the Reducing Primary Cesarean Learning Collaborative from the American College of Nurse-Midwives.

SETTING

A Level II regional hospital in Virginia with more than 2,600 births annually. Births are attended by certified nurse-midwives and physicians.

PARTICIPANTS

Nursing staff on the labor and delivery unit in March 2016 (n = 27), September 2017 (n = 20), and June 2019 (n = 24).

INTERVENTION/MEASUREMENTS

We updated policies, educated nurses, procured labor support equipment, and modified documentation of care. We measured nurse confidence and skill in labor support techniques with the Self-Efficacy Labor Support Scale over 4 years. We tracked how many women were provided continuous labor support and the primary cesarean birth rate among women who were nulliparous and low risk.

RESULTS

Nurses' mean self-efficacy scores increased from 76.67 in 2016 to 86.96 in 2019 (p < .001). The proportion of women who were provided continuous labor support increased from a baseline of 4.38% (47/1,074) in January 2015 through March 2016 to 18.06% (82/454) in July through December 2019 (p < .001). The primary cesarean birth rate for nulliparous women with low-risk pregnancies remained stable, at approximately 18% from 2015 to 2019.

CONCLUSION

Implementation of the Comfort in Labor Safety Bundle improved nurse self-efficacy in labor support techniques and increased the frequency of continuous labor support.