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.

Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing.

The Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing charts an efficient pathway to a maternity care system that reliably enables all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences. The authors are members of a multistakeholder, multidisciplinary National Advisory Council that collaborated to develop this document. This approach preventively addresses troubling trends in maternal and newborn outcomes and persistent racial and other disparities by mobilizing innate capacities for healthy childbearing processes and limiting use of consequential interventions. It provides more appropriate care to healthier, lower-risk women and newborns who often receive more specialized care, though such care may not be needed and may cause unintended harm. It also offers opportunities to improve the care, experience and outcomes of women with health challenges by fostering healthy perinatal physiologic processes whenever safely possible.

The American College of Nurse-Midwives Clarity in Collaboration Project: Describing Midwifery Care in Interprofessional Collaborative Care Models.

In 2014, the American College of Nurse-Midwives (ACNM) launched a project called Clarity in Collaboration to develop data definitions related to midwifery and maternity care delivery processes. These definitions are needed to ensure midwifery care delivered in collaborative care models is accurately and consistently captured in clinical documentation systems, data registries, and systems being developed as part of health care restructuring and payment reform. The Clarity in Collaboration project builds on the efforts of the Women's Health Registry Alliance (WHRA), which was recently established by the American College of Obstetricians and Gynecologists. Clarity in Collaboration mirrored the process used by ReVITALize, WHRA's first maternity data standardization project, which focused on establishing standardized clinical data definitions for obstetrics. The ACNM Clarity in Collaboration project brought together maternity and midwifery care experts to complete a year-long consensus process, including a period of public comment, resulting in development of 20 concept definitions. These definitions can be used to describe midwifery care within the context of collaborative care models. This article provides a summary of the ACNM Clarity in Collaboration process with discussion of implications for maternity data collection.

Hormonal Physiology of Childbearing, an Essential Framework for Maternal-Newborn Nursing.

Knowledge of the hormonal physiology of childbearing is foundational for all who care for childbearing women and newborns. When promoted, supported, and protected, innate, hormonally driven processes optimize labor and birth, maternal and newborn transitions, breastfeeding, and mother-infant attachment. Many common perinatal interventions can interfere with or limit hormonal processes and have other unintended effects. Such interventions should only be used when clearly indicated. High-quality care incorporates salutogenic nursing practices that support physiologic processes and maternal-newborn health.

Continuing education module transforming maternity care: implementing the blueprint for action.

In January 2010, Women's Health Issues published two direction-setting reports from the Transforming Maternity Care (TMC) Project: "2020 Vision for a High-Quality, High-Value Maternity Care System" and "Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System." This guest editorial summarizes highlights of the implementation phase of what is now known as the TMC Partnership. Major progress has been made in elevating maternity care quality to a national policy priority, increasing the availability and use of maternity care performance measures, and developing shared decision making tools for childbearing women.

Social Media, Power, and the Future of VBAC.

The Internet has been called a disruptive technology because it has shifted power and altered the economics of doing business, whether that business is selling books or providing health care. Social media have accelerated the pace of disruption by enabling interactive information sharing and blurring the lines between the "producers" and "consumers" of knowledge, goods, and services. In the wake of the National Institutes of Health Consensus Development Conference on Vaginal Birth After Cesarean (VBAC) and major national recommendations for maternity care reform, activated, engaged consumers face an unprecedented opportunity to drive meaningful changes in VBAC access and safety. This article examines the role of social networks in informing women about VBAC, producing low-cost, accessible decision aids, and enabling multi-stakeholder collaborations toward workable solutions that remove barriers women face in accessing VBAC.

They said so on the news: parsing media reports about birth.

In this column, the authors reprise recent selections from the Lamaze International research blog, Science & Sensibility. Each selection discusses shortcomings in the news media coverage of childbirth issues. The authors demonstrate how to identify misleading claims in the media and highlight how childbirth educators can apply a common-sense approach and careful fact checking to help women understand the whole story.

Safe and healthy birth: the importance of data.

In this column, the author reprises recent selections from the Lamaze International research blog, Science & Sensibility. Each selection discusses the mismatch between data commonly collected at the time of birth and the data needed to measure optimal care for physiologic birth. Selections include the importance of documenting duration of skin-to-skin contact after birth, the role of qualitative research in improving care in the second stage of labor, and pitfalls of meta-analyzing data on the safety of planned home birth.

Creating a culture of consumer engagement in maternity care.

In this column, the author reprises recent selections from the Lamaze International research blog, Science & Sensibility. Each selection discusses opportunities to establish a culture of consumer engagement in maternity care. The author demonstrates how improving health literacy, ensuring multi-stakeholder participation in the development of clinical guidelines, and supporting comparative effectiveness research of woman- and family-centered care practices may improve maternity care.

Deconstruction junction: how to separate the good evidence from the bad (from the ugly).

In this column, the author reprises recent selections from the Lamaze International research blog, Science & Sensibility. Each selection discusses a new study that demonstrates the need to look closely at research articles to avoid being misled. Examples include new research on the effectiveness of intrapartum antibiotics for preventing early onset Group B streptococcal disease in newborns, a recent study on the incidence of infection after cesarean surgery and vaginal birth, and a new study demonstrating long-term benefits of skin-to-skin contact between the mother and infant after birth.

First, do no harm: how routine interventions, common restrictions, and the organization of our health-care system affect the health of mothers and newborns.

In this column, the author reprises recent selections from the Lamaze International research blog, Science & Sensibility. Each selection discusses a new study that demonstrates the "First, do no harm" principle in a different way. New research on the potentially harmful effects of intravenous lines demonstrates that refraining from routine interventions in labor protects the safety of women and babies. A new systematic review of movement and position changes in labor shows that eliminating unfounded restrictions also protects maternal and infant health and well-being. Finally, a study of patterns of use of neonatal intensive care units reveals how the organization of the maternity care system itself can affect the health outcomes of its beneficiaries.

Promoting, protecting, and supporting normal birth: a look at the evidence.

Interfering with the normal physiological process of labor and birth in the absence of medical necessity increases the risk of complications for mother and baby. Six evidence-based care practices promote physiological birth: avoiding medically unnecessary induction of labor, allowing freedom of movement for the laboring woman, providing continuous labor support, avoiding routine interventions and restrictions, encouraging spontaneous pushing in nonsupine positions, and keeping mothers and babies together after birth without restrictions on breastfeeding. Nurses are in a unique position to provide these care practices and to help childbearing women make informed choices based on evidence.

Research summaries for normal birth.

In this column, the authors summarize four research studies relevant to normal birth. Topics of the studies summarized include the harms of screening for macrosomia late in pregnancy, the risk factors for and impact of postpartum pain in childbearing women, the effects of a breastfeeding approach called "biological nurturing" on reflexive behavior in newborns, and the effects of prenatal yoga on labor and birth outcomes.

Research summaries for normal birth.

In this column, the author summarizes four research studies relevant to normal birth. The topics of the studies summarized include the effect of obstetrician anxiety on cesarean surgery rates, the risks of routine membrane sweeping, beneficial effects of doula care for middle-class women, and the lack of reliability of continuous electronic fetal monitoring tracings.

Research summaries for normal birth.

In this column, the author summarizes research studies relevant to normal birth. The studies summarized include a large trial evaluating the effect of prior vaginal births after a cesarean on outcomes in subsequent births; a study linking umbilical cord blood pH with intellectual outcomes in childhood; and a prospective trial evaluating the effect of routine antenatal nonstress testing on maternal anxiety. The author also highlights four articles about normal birth in a recent nursing journal series dedicated to the topic.

Research summaries for normal birth.

In this column, the author summarizes four research studies relevant to normal birth. The studies summarized include a systematic review of trials evaluating the benefits versus harms of routine artificial rupture of the membranes; a study of the effect of continuous female labor support by a minimally trained family member or friend on attachment and early parenting; a systematic review examining the relationship between cesarean surgery and postpartum urinary incontinence; and a randomized controlled trial of warm perineal compresses during the second stage of labor.

Research summaries for normal birth.

In this column, the authors summarize four research studies that further support the benefits of normal birth. The topics of the studies include the association of cesarean birth with an increased risk of neonatal death; the use of acupuncture and self-hypnosis as effective pain-management strategies; factors associated with amniotic-fluid embolism; and the positive influence of continuous support by lay doulas on obstetric outcomes for low-income women.