A competency based approach to comprehensive pregnancy care

This paper assesses the quality and cost of a pregnancy care program based on explicit and achieved patient competencies. By using the USPHS Content of Prenatal Care (1989), key psychosocial/education elements of perinatal care were identified. The goal was a process of patient education that is competency based, integrated, and outcome oriented. Psychosocial assessment, patient education tools, criterion-based length of postpartum stay, and home nursing follow-up were implemented as part of a Comprehensive Pregnancy Program (CPP). Case-control and cohort survey methodology were used to evaluate outcome. There was a significant decrease in hospital length of stay for mothers and newborns after implementation of the CPP. Post-discharge maternal emergency room visits and/or readmits did not increase. Differences in newborn emergency room visits and/or readmits were non-significant. There was a marked reduction in hospital costs for mothers and newborns. Patient satisfaction remained high. Core competencies forming the basis of educational and assessment programs allow the focus of care to be optimal outcome, and provide a useful template against which to measure prenatal, intrapartum, and postpartum care.

Working conditions and adverse pregnancy outcome: a meta-analysis

OBJECTIVE

To evaluate the association between working conditions and adverse pregnancy outcomes by performing a meta-analysis of published studies.

DATA SOURCES

We searched the English-language literature in MEDLINE through August 1999 using the terms standing, posture, work, workload, working conditions, shift, occupational exposure, occupational diseases, lifting, pregnancy complications, pregnancy, small for gestational age (SGA), fetal growth retardation (FGR), preterm, and labor.

METHODS OF STUDY SELECTION

We included observational studies evaluating the effect of one or more of the following work-related exposures on adverse pregnancy outcome: physically demanding work, prolonged standing, long work hours, shift work, and cumulative work fatigue score. Outcomes of interest were preterm birth, hypertension or preeclampsia, and SGA.We conducted a meta-analysis based on 160,988 women in 29 studies to evaluate the association of physically demanding work, prolonged standing, long working hours, shift work, and cumulative work fatigue score with preterm birth. Also analyzed were the associations of physically demanding work with hypertension or preeclampsia and SGA infants. The data were analyzed using the Peto-modified Mantel-Haenszel method to estimate the pooled odds ratios (ORs) and 95% confidence intervals (CIs).

TABULATION, INTEGRATION, AND RESULTS

Physically demanding work was significantly associated with preterm birth (OR 1.22, 95% CI 1.16, 1. 29), SGA (OR 1.37, 95% CI 1.30, 1.44), and hypertension or preeclampsia (OR 1.60, 95% CI 1.30, 1.96). Other occupational exposures significantly associated with preterm birth included prolonged standing (OR 1.26, 95% CI 1.13, 1.40), shift and night work (OR 1.24, 95% CI 1.06, 1.46), and high cumulative work fatigue score (OR 1.63, 95% CI 1.33, 1.98). We found no significant association between long work hours and preterm birth (OR 1.03, 95% CI 0.92, 1.16).

CONCLUSION

Physically demanding work may significantly increase a woman's risk of adverse pregnancy outcome.

Work and pregnancy: the role of fatigue and the "second shift" on antenatal morbidity

OBJECTIVE

This study was undertaken to evaluate factors at home and work associated with antenatal morbidity (emergency department visits and hospitalizations) among employed pregnant women.

STUDY DESIGN

This prospective study of 213 women included 3 antenatal interviews at about 16, 24, and 30 weeks' gestation with questions on health history, lifestyle, housework, working conditions, and emergency department visits and hospitalizations. Work scores and home scores were formulated from each interview. Fatigue was defined as being very tired or extremely tired at the end of a typical workday. The risk of antenatal morbidity was modeled by means of logistic regression; results are presented as adjusted odds ratios with 95% confidence intervals.

RESULTS

The risk of antenatal morbidity, which was greatest during the second trimester, was increased by stress (adjusted odds ratio, 2.45; 95% confidence interval, 1.32-4.57), fatigue (adjusted odds ratio, 3.77; 95% confidence interval, 1.98-7.18), work plus home score (adjusted odds ratio, 1.55; 95% confidence interval, 1.22-1.97), and the interaction of fatigue and work plus home score (adjusted odds ratio, 4.61; 95% confidence interval, 2.02-10.50).

CONCLUSIONS

These findings suggest that maternal fatigue contributes significantly to antenatal morbidity.

The importance of early weight gain in the intrauterine growth and birth weight of twins

OBJECTIVE

It was our objective to evaluate the association between early maternal weight gain (before 20 weeks), midpregnancy weight gain (20-28 weeks), and late pregnancy weight gain (28 weeks to birth) with fetal growth and birth weight in twins.

STUDY DESIGN

This historic cohort study was based on 1564 births of live twins >/=28 weeks' gestation from Baltimore, Maryland, Miami, Florida, Charleston, South Carolina, and Ann Arbor, Michigan.

RESULTS

Early fetal growth was affected only by smoking and chorionicity. Factors in models of both mid and late fetal growth included maternal age, pregravid weight, parity, rates of early pregnancy and midpregnancy maternal weight gain, smoking, and pre-eclampsia. Increased midpregnancy fetal growth was associated with early maternal weight gain (10.91 g/wk per pound per week) and midpregnancy maternal weight gain (15.89 g/wk per pound per week). Increased late fetal growth was associated with early maternal weight gain (16.86 g/wk per pound per week) and midpregnancy maternal weight gain (23.88 g/wk per pound per week). Increased birth weight was associated with early (283.02 g per pound per week), mid (163.58 g per pound per week), and late (69.76 g per pound per week) maternal weight gains.

CONCLUSIONS

These findings confirm the importance of early maternal weight gain in twin fetal growth and birth weight.

Critical periods of maternal weight gain: effect on twin birth weight

OBJECTIVE

Our purpose was to evaluate the association between maternal weight gain and twin birth weight.

STUDY DESIGN

This historic cohort study was based on 646 live-born twin births of > or = 28 weeks from Baltimore, Maryland, Miami, Florida, and Ann Arbor, Michigan. The sum of twin-pair birth weight was modeled as a function of either net maternal weight at delivery or rates of maternal weight gain with use of multiple regression.

RESULTS

Birth weight was significantly associated with weight gain before 20 weeks in underweight women, before 20 weeks and after 28 weeks in overweight women, and during all three gestational periods in normal-weight women. Weight gain before 20 weeks had the largest effect on infants of underweight women, less of an effect on infants of normal-weight women, and half as much effect on infants of overweight women. Weight gain after 28 weeks significantly affected the infant birth weights of normal-weight and overweight women, but the effect was half as great among infants of the latter group.

CONCLUSIONS

These findings suggest that weight gain during critical periods of gestation significantly influences twin birth weight; these critical periods vary by maternal pregravid weight status.

Kinetics of the pituitary-thyroid axis and the peripheral thyroid hormones in 2 children with thyroxine intoxication

Thyroxine intoxication is a benign, nonfatal condition, relatively common in the pediatric age group. We present here a detailed laboratory follow-up of all thyroidal hormones in 2 healthy girls who inadvertently ingested 2,500 micrograms of L-thyroxine. The two girls were hospitalized and treated with ipecac, gastric lavage, propranolol, prednisone, cholestyramin and propyl-thiouracil. All physical signs were normal and no symptoms were reported. All thyroidal hormones were measured 12 times from 2 h to 20 days after the ingestion. For T4, T3, rT3 and thyroglobulin (Tg) a one-compartment kinetic model was formulated and fitted to the empirical data. The kinetic data constants of production and elimination were calculated, as well as the metabolic clearance rate. All laboratory values were similar in both girls. T4 serum levels were already high 2 h after the intoxication and returned to normal values only after 13 days. Fitting the T4 serum levels with a one-compartment model resulted in absorption and degradation constants similar to those in normal adult subjects. Thyroid-stimulating hormone (TSH) levels decreased reaching their lowest concentration 14 h after the intoxication. They remained low till the 4th day, after which they rose gradually. Twenty days after the intoxication, TSH levels were still below their initial values. T3 reached its peak levels 11 h after the ingestion and decreased to normal values after 3 days. Both T3 production constants and T3 degradation constants were significantly increased. rT3 reached its peak level on the 2nd day after the intoxication and decreased to normal values on the 4th day. Its production and degradation constants were somewhat below normal levels. The T3/rT3 ratio decreased from a normal level of around 3 to as low as 1 and rose again after 13 days to extremely high levels (as high as 8). Tg serum levels dropped continuously with a half-life of 1-5 days and started rising again after 2-13 days. In conclusion, T4 intoxication in the child is combated primarily by a significant increase in T3 production and degradation, while meticulously maintaining relatively low T3 levels.