Low‐Interventional Approaches to Intrapartum Care: Hospital Variation in Practice and Associated Factors

The effect of intrapartum care model given in line with world health organization (WHO) recommendations on labor pain, fear of labor, comfort of labor, duration of labor, administration of oxytocin and perception of midwifery care: a randomized controlled study

OBJECTIVES

This study aimed to assess the impact of a WHO-aligned intrapartum care model on labor aspects, including pain, fear, comfort, labor duration, oxytocin use, and perceptions of supportive care.

METHODS

This is a randomized controlled study. The study was conducted with 124 primiparous pregnant women (intervention group n = 62, control group n = 62) who were admitted to the maternity unit of a hospital in Central Anatolia, Türkiye. The intervention group was subjected to the intrapartum care model, once cervical dilatation reached 5 cm. The control group received only standard intrapartum care in the hospital.

RESULTS

The Visual Analog Scale (VAS) scores for the pregnant women in the intervention group who received intrapartum care in accordance with WHO recommendations were significantly lower than those for the control group (p < 0.001). The pregnant women in the intervention group exhibited lower fear of labor scores and higher comfort of labor scores during the active phase than those in the control group (p < 0.001). Furthermore, the duration of the first, second, and third stages of labor was observed to be significantly shorter in the intervention group compared to the control group (p < 0.001). Additionally, the use of oxytocin was found to be less prevalent in the intervention group compared to the control group (p < 0.001). Furthermore, the mean scores of the scale measuring women's perception of supportive care during labor were found to be significantly higher in the intervention group compared to the control group (p < 0.001).

CONCLUSION

In alignment with these findings, it is recommended that midwives and obstetricians implement the intrapartum care model in accordance with the World Health Organization's (WHO) recommendations. The implementation of this model aims to reduce labor pain, fear, and oxytocin use, enhance women's perception of birth comfort and care, and transform the birth experience into a more positive one.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov identifier NCT06681675.

Defining Midwifery-Led Care in the United States Using Concept Analysis

National health policy initiatives recommend increased integration of midwifery care in the United States to improve care quality and reduce maternal health disparities. However, the service models through which midwives provide midwifery care and produce quality outcomes are poorly understood. Midwifery-led care is a service model frequently associated with improved outcomes compared with other models. The service model has been infrequently or inconsistently studied in the Unites States and has been narrowly defined and applied to perinatal care. The purpose of this concept analysis was to evaluate the concept of midwifery-led care and expand the definition to guide midwifery practice, research, and health policy. The analysis followed Walker and Avant's methodology. Three attributes of midwifery-led care were identified: (1) midwife as the lead clinician; (2) person-midwife partnership; and (3) care embodies midwifery philosophy. Antecedents were (1) license to practice as a midwife; (2) a person needing or desiring sexual, reproductive, perinatal, or newborn care; (3) a person with low- or moderate-risk health status; (4) regulations and guidelines that support provision of midwifery care; and (5) reimbursement for services. Consequences of midwifery-led care included (1) improved maternal and neonatal outcomes, (2) patient satisfaction, and (3) reduced health care costs. The presented expanded definition of midwifery-led care is the first to use a systems level approach and explicitly center the person receiving care and the philosophical approach of midwifery care. Application of this definition is needed in theoretical and pragmatic research to classify midwifery-led care and other service models and compare patient- and organization-level outcomes.

Intrapartum Quality of Care among Healthy Women: A Population-Based Cohort Study in an Italian Region

Although the quality of care during childbirth is a maternity service's goal, less is known about the impact of the birth setting dimension on provision of care, defined as evidence-based intrapartum midwifery practices. This study's aim was to investigate the impact of hospital birth volume (≥1000 vs. <1000 births/year) on intrapartum midwifery care and perinatal outcomes. We conducted a population-based cohort study on healthy pregnant women who gave birth between 2018 and 2022 in Lombardy, Italy. A total of 145,224 (41.14%) women were selected from nationally linked databases. To achieve the primary aim, log-binomial regression models were constructed. More than 70% of healthy pregnant women gave birth in hospitals (≥1000 births/year) where there was lower use of nonpharmacological coping strategies, higher likelihood of epidural analgesia, episiotomy, birth companion's presence at birth, skin-to-skin contact, and first breastfeeding within 1 h (p-value < 0.001). Midwives attended almost all the births regardless of birth volume (98.80%), while gynecologists and pediatricians were more frequently present in smaller hospitals. There were no significant differences in perinatal outcomes. Our findings highlighted the impact of the birth setting dimension on the provision of care to healthy pregnant women.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Fifty Years of the Rise in Cesarean Birth in the United States and Opportunities for Improvement

Factors that shaped and promoted cultural norms in the 1900s continue to influence current obstetric practice today. The incidence of cesarean birth too often has little to do with the health needs of the woman or the fetus and more to do with multiple factors over which the woman has no control. Nurses and midwives can reduce unnecessary cesarean births and have the necessary knowledge, competence, and skills to help women give birth without medical intervention.

Breastfeeding as a Quality Measure: Demonstrating Levers of the National Quality Strategy

The purpose of this study is to explore the National Quality Strategy (NQS) levers (measurement and feedback, public reporting, learning and technical assistance, and certification) on state and national breastfeeding performance. The research evaluates the NQS levers of measurement and feedback and public reporting using secondary data analysis of publicly reported data from the National Immunization Survey and the Centers for Disease Control and Prevention Breastfeeding Report Cards between 2008 and 2018, the latest years available. Linear regression explores the association between the prevalence of state-level Baby-Friendly hospitals and state-level breastfeeding rates. Subsequent analyses use event study to test whether state-level Baby-Friendly hospital adoption is associated with higher breastfeeding rates. A 10% increase in Baby-Friendly hospitals at the state level is associated with increased population breastfeeding rates by nearly 5% and a decrease in early formula use (before 2 days of life) by 2% to 9%. Breastfeeding increased by 2% to 5% in the first 2 years following state-level Baby-Friendly initiatives, with subsequent increases up to 10% in the next 4 years. The National Quality Strategy levers of measurement and public reporting combined with certification and learning and technical assistance are associated with increases in exclusive breastfeeding, a national quality metric.

Trial of Labor After Two Prior Cesarean Deliveries: Patient and Hospital Characteristics and Birth Outcomes

OBJECTIVE

Trial of labor after cesarean delivery has been mostly studied in the setting of one prior cesarean delivery; controversy remains regarding the risks and benefits of trial of labor for women with two prior cesarean deliveries. This study aimed to examine utilization, success rate, and maternal and neonatal outcomes of trial of labor in this population.

METHODS

Using linked hospital discharge and birth certificate data, we retrospectively analyzed a cohort of mothers with nonanomalous, term, singleton live births in California between 2010-2012 and had two prior cesarean deliveries and no clear contraindications for trial of labor. We measured whether they attempted labor and, if so, whether they delivered vaginally. Association of patient and hospital characteristics with the likelihood of attempting labor and successful vaginal birth was examined using multivariable regressions. We compared composite severe maternal morbidities and composite severe newborn complications in those who underwent trial of labor as opposed to planned cesarean delivery using a propensity score-matching approach.

RESULTS

Among 42,771 women who met sample eligibility criteria, 1,228 (2.9%) attempted labor, of whom 484 (39.4%) delivered vaginally. There was no significant difference in the risk of composite severe maternal morbidities, but there was a modest increase in the risk of composite severe newborn complications among women who attempted labor compared with those who did not (2.0% vs 1.4%, P=.04). After accounting for differences in patient and hospital characteristics, propensity score-matched analysis showed no significant association between trial of labor and the risk of composite severe maternal morbidities (odds ratio [OR] 1.16, 95% CI 0.70-1.91), but trial of labor was associated with a higher risk for the composite of severe newborn complications (OR 1.78, 95% CI 1.04-3.04).

CONCLUSION

Among women with two prior cesarean deliveries, trial of labor was rarely attempted and was successful in 39.4% of attempts. Trial of labor in this population was associated with a modest increase in severe neonatal morbidity.

The evolution of professional obstetric nursing in the United States (1880's-present): Qualitative content analysis of specialty nursing textbooks

Background

Professional maternal-newborn/obstetric nursing in the United States emerged in the mid- 19th century coinciding with the increased medical management of childbirth. Before this mothers were attended by female family members, friends, neighbors and lay nurses or midwives.

Objective

To trace the evolution of professional maternal-newborn/obstetric nursing since its inception, identify factors which may have influenced this evolution, and consider how this knowledge can inform current issues and challenges in caring for childbearing families.

Methods

Qualitative content analysis, informed by historical research methods, was used to analyze selected content from a sample of maternal-newborn/obstetric nursing textbooks published from the 1880's to the present.

Findings

The last 150 years have been characterized by vast changes in medicine, technology and the healthcare system which have all influenced the evolution of professional maternal-newborn/obstetric nursing. Over the decades there has also been a significant change in the conceptualization of pregnancy/childbearing and our relative understanding of maternal and infant vulnerability. Findings revealed, however, that over time the primary focus of professional maternal-newborn/obstetric nursing care has consistently been: "protection, counseling/teaching and support" of childbearing families. In the U.S. maternal-newborn/obstetric nurses currently face many challenges including caring for an increasingly diverse patient population within a complex, technologically advanced healthcare system. This system is characterized by a high rate of cesarean section births, frequent intervention in vaginal births, disparities in access to care, and a high rate of preventable morbidity and mortality.

Conclusions

Since its origins the nursing profession has matured and nursing's allegience is now clearly to patients and society Today's nurses have the opportunity to play a key role in advocating for healthcare reform which would allow for less interference in the natural birth process, maximize patient outcomes, decrease inequities, and make comprehensive care for all mothers and infants a national priority.

A Multimethod Improvement Project to Strengthen Intermittent Auscultation Practice Among Nurse-Midwives and Nurses

INTRODUCTION

Intermittent auscultation (IA) is an accepted standard of care for intrapartum fetal assessment for low-risk individuals and is the exclusive method used to monitor fetal status in birth centers. However, there are conflicting national guidelines for practice and skill training. As a result, IA technique and skills vary across the perinatal care workforce, with many health care providers receiving no or minimal formal training. This article describes the design, implementation, and evaluation of a quality improvement program aimed at strengthening the IA skills of nurse-midwives and nurses.

PROCESS

The project was implemented in a multisite network of freestanding birth centers and involved clinical practice guideline development, simulation-based training, audit and feedback, in-person training, and electronic health record configuration.

OUTCOMES

The training resulted in self-reported increases in knowledge in all areas assessed. The integrated quality improvement initiative resulted in substantial improvements in consistency of practice and documentation.

DISCUSSION

Policy change was not sufficient to improve use of IA, a nuanced skill that many midwives and nurses have limited exposure to in basic education programs and hospital-based clinical practice. Clinical improvement was possible when the policy change was accompanied by a comprehensive training and implementation strategy including interactive, simulation-based learning, audit and feedback, and an electronic health record configuration that better reflected the documentation standards.