Assessing fetal movements in pregnancy: A qualitative evidence synthesis of women's views, perspectives and experiences.

BACKGROUND: Raising awareness of the importance of fetal movements (FMs) and advising women on the appropriate action to take if they experience reduced FMs, is important for minimising or avoiding adverse perinatal outcomes. To gain insight and understanding of women's perspectives of assessing FMs in pregnancy, we conducted a qualitative evidence synthesis. METHODS: A qualitative evidence synthesis using thematic synthesis was conducted. Studies were eligible if they included pregnant women who were at least 20 weeks gestation and reported qualitative data from women on assessing FMs in pregnancy. MEDLINE, CINAHL, EMBASE, PsycINFO and Social Science Citation Index, from inception to July 2020, were searched. The methodological quality of included studies was assessed by at least two reviewers using an Evidence for Policy and Practice Information (EPPI)-Centre quality assessment tool. Data synthesis, using the Thomas and Harden framework, involved line by line coding of extracted data, establishing descriptive themes, and determining analytical themes. Confidence in the findings was assessed using GRADE CER-Qual. RESULTS: Nine studies, involving 2193 women, were included in the review. The methodological quality of the studies was overall generally high. The synthesis revealed three dominant themes, and seven sub-themes that reflected women's perspectives of assessing FMs in pregnancy. These were; 1) How women engage with FMs, with subthemes of informal engagement, formal engagement, and strategies to stimulate FMs; 2) ' … like a feather inside my belly' - articulating and describing FMs, with sub-themes of sensations associated with FMs and timing and frequency of FMs; and 3) FMs and help/health seeking, with sub-themes of information sources and interacting with healthcare professionals. Confidence in the findings was either high or moderate, although two findings were rated low confidence and one very low. CONCLUSION: This qualitative evidence synthesis reveals that women informally engage with FMs during pregnancy. Women commonly adopt strategies to stimulate FMs when concerned. The use of the internet was a common source of obtaining information regarding FMs. Women require better support when contacting healthcare professionals about FMs. As only three of the nine included studies were exclusively qualitative in design, further qualitative studies exploring women's perspective of assessing FMs in pregnancy are required.

Longer Time Before Acute Rehabilitation Therapy Worsens Disability After Intracerebral Hemorrhage.

OBJECTIVE: Assess the association of time to initiation of acute rehabilitation therapy with disability after intracerebral hemorrhage (ICH) and identify predictors of time to initiation of rehabilitation therapy. DESIGN: Retrospective data analysis of prospectively collected data from an ongoing observational cohort study. SETTING: Large comprehensive stroke center in a metropolitan area. PARTICIPANTS: Adults with ICH consecutively admitted (n=203). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disability was assessed with the modified Rankin Scale (mRS), with poor outcome defined as mRS 4-6 (dependence or worse). Time to initiation of acute rehabilitation therapy was defined as the number of days between hospital admission and the first consult by any rehabilitation therapy specialist (eg, physical therapy, occupational therapy, speech therapy). RESULTS: The median number of days from hospital admission to initiation of acute rehabilitation therapy was 3 (range=2-7). Multivariable logistic regression models indicated that each additional day between admission and initiation of acute rehabilitation therapy was associated with increased odds of poor outcome at 30 days (adjusted odds ratio [OR]=1.151; 95% confidence interval [CI]=1.044-1.268; P=.005) and at 90 days (adjusted OR=1.107; 95% CI=1.003-1.222; P=.044) for patients with ICH. A multivariable linear regression model used to identify the predictors of time to initiation of rehabilitation therapy identified heavy drinking (>5 drinks per day), premorbid mRS<4, presence of pulmonary embolism, and longer length of stay in the intensive care unit as independent predictors of later initiation of acute rehabilitation therapy. CONCLUSIONS: Longer time to initiation of acute rehabilitation therapy after ICH may have persistent effects on poststroke disability. Delays in acute rehabilitation therapy consults should be minimized and may improve outcomes after ICH.

Prophylactic Seizure Medication and Health-Related Quality of Life After Intracerebral Hemorrhage.

OBJECTIVES: Prophylactic levetiracetam is currently used in ~40% of patients with intracerebral hemorrhage, and the potential impact of levetircetam on health-related quality of life is unknown. We tested the hypothesis that prophylactic levetiracetam is independently associated with differences in cognitive function health-related quality of life. DESIGN: Patients with intracerebral hemorrhage were enrolled in a prospective cohort study. We performed mixed models for T-scores of health-related quality of life, referenced to the U.S. population at 50 ± 10, accounting for severity of injury and time to follow-up. SETTING: Academic medical center. PATIENTS: One-hundred forty-two survivors of intracerebral hemorrhage. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: T-scores of Neuro-Quality of Life Cognitive Function v2.0 was the primary outcome, whereas Neuro-Quality of Life Mobility v1.0 and modified Rankin Scale (a global functional scale) were secondary measures. We prospectively documented if prophylactic levetiracetam was administered and retrieved administration data from the electronic health record. Patients who received prophylactic levetiracetam had worse cognitive function health-related quality of life (T-score 5.1 points lower; p = 0.01) after adjustment for age (p = 0.3), National Institutes of Health Stroke Scale (p < 0.000001), lobar hematoma (p = 0.9), and time of assessment; statistical models controlling for prophylactic levetiracetam and the Intracerebral Hemorrhage Score, a global measure of intracerebral hemorrhage severity, yielded similar results. Lower T-scores of cognitive function health-related quality of life at 3 months were correlated with more total levetiracetam dosage (p = 0.01) and more administered doses of levetiracetam in the hospital (p = 0.03). Patients who received prophylactic levetiracetam were more likely to have a lobar hematoma (27/38 vs 19/104; p < 0.001), undergo electroencephalography monitoring (15/38 vs 21/104; p = 0.02), but not more likely to have clinical seizures (4/38 vs 7/104; p = 0.5). Levetiracetam was not independently associated with the modified Rankin Scale scores or mobility health-related quality of life (p > 0.1). CONCLUSIONS: Prophylactic levetiracetam was independently associated with lower cognitive function health-related quality of life at follow-up after intracerebral hemorrhage.

Effect of frenotomy on breastfeeding variables in infants with ankyloglossia (tongue-tie): a prospective before and after cohort study.

BACKGROUND: Controversy exists regarding ankyloglossia (tongue-tie) and its clinical impact on breastfeeding, including the benefits, or otherwise, of tongue-tie release (frenotomy). As exclusive breastfeeding rates in Ireland are already considerably low (46% on discharge home from the maternity unit following birth in 2014), it is imperative to protect and support breastfeeding, including identifying the associated effects that frenotomy might have on breastfeeding variables. OBJECTIVE: To determine the associated effects of frenotomy on breastfeeding variables in infants with ankyloglossia. METHODS: A prospective before and after cohort study was conducted. Following ethical approval, two self-reported questionnaires were administered to women whose infants were undergoing frenotomy at seven healthcare clinics in the Republic of Ireland. Data on breastfeeding variables prior to the frenotomy procedure and at 1-month post-frenotomy were collected and compared. Descriptive statistics (frequencies and proportions) were used to analyse, separately, the pre- and post-frenotomy data. Inferential statistics (z-test scores for differences between proportions (alpha <0.05) and mean differences (MD) with 95% confidence intervals (CI)) were used for pre- and post-frenotomy comparative analyses. RESULTS: Ninety-eight women returned the baseline questionnaire, and, of these, 89 returned the follow-up questionnaire. The most common reason for seeking a frenotomy was difficulty with latch (38%). Private lactation consultants were the main person recommending a frenotomy (31%). Rates of exclusive breastfeeding remained similar pre- and post-frenotomy (58% versus 58%), although rates of formula feeding increased two-fold at follow-up. Infants' ability to extend their tongues to the lower lip after frenotomy was significantly increased (p < 0.0001). Almost all participants (91%) reported an overall improvement in breastfeeding post-frenotomy. Pain on breastfeeding was significantly reduced post-frenotomy (MD 2.90, 95% CI 3.75 to 2.05) and overall LATCH scale scores were significantly increased (MD -0.50, 95% CI -0.67 to -0.33). CONCLUSIONS: This study supports the hypothesis that frenotomy has a positive effect on breastfeeding variables in infants with ankyloglossia. These findings, however, are based on a relatively small number of participants from one country only where breastfeeding rates are low. Further, larger studies are required to substantiate these findings.

The Support Needs and Current Practices of Public Health Nurses in the Republic of Ireland Who Provide Support to Breastfeeding Mothers: A Cross-Sectional Survey.

BACKGROUND: Breastfeeding continuation rates are low in Ireland. The Breastfeeding Observation and Assessment Tool (BOAT) was developed to assist public health nurses in assessing breastfeeding challenges; however, little is known of its actual usage, the level of training experienced or desired by public health nurses, or their level of confidence in the support they provide to breastfeeding mothers. RESEARCH AIM: To identify the current practices and support needs of public health nurses who provide breastfeeding support in Ireland. METHOD: An online questionnaire was devised to collect respondents' confidence with breastfeeding issues, caseload, and practices. It was distributed to public health nurses with a current child health caseload in one Community Healthcare Organization. Mann Whitney U tests were used to ascertain the relationship between public health nurses' confidence level and those with qualifications in midwifery or as an International Board Certified Lactation Consultant (IBCLC). RESULTS: The survey was completed by 66 public health nurses. Only 14 respondents (21.2%) indicated that they always used the BOAT. The most common reason for not doing so was a lack of education on its use (n = 17, 25.8%). Postholders also certified as IBCLCs were considered by participants to be the most appropriate professionals to resolve certain breastfeeding issues. Confidence levels to manage breastfeeding issues were highest among public health nurses with IBCLC credentialing (U = 12.5, p = .001) while no difference was seen when comparing those with a midwifery degree to those without (U = 184.0, p = .92). Face-to-face workshops and blended-learning approaches were ranked as the preferred formats for breastfeeding education (Median rank = 2). CONCLUSIONS: Breastfeeding education incorporating a face-to-face component is needed to support public health nurses who work with breastfeeding mothers, as is prioritization of recruitment in the community of public health nurses with IBCLC credentials.

An evaluation of the appropriateness and effectiveness of structured reflection for midwifery students in Ireland.

Midwifery students undertaking the undergraduate midwifery education programme in Ireland participate in facilitated reflective sessions that aim to develop their skills of reflecting on and in clinical practice. This paper presents a qualitative evaluation of the appropriateness and effectiveness of the facilitated reflection sessions for pre and post-registration midwifery students in two large Dublin maternity teaching hospitals. The aim was to evaluate structured reflective practice sessions which sought to assist midwifery students to become competent reflective practitioners. Group reflection sessions were conducted weekly in a clinical practice area at the same time each week over one academic year. After the series of structured reflective sessions, midwifery students and facilitating staff were invited to evaluate the reflective process. This evaluation consisted of a self-completion survey to identify the factors that facilitated and impeded student participation in the sessions. Respondents answered a series of questions about the reflective practice sessions and were also invited to enter qualitative data regarding their subjective experiences of the process in free text boxes. The data were then collated into themes by an independent reviewer. The results of the evaluation clearly indicate that midwifery students and facilitators welcomed the opportunity to engage in group reflection sessions as a form of peer support and as a catalyst for learning from clinical practice. Findings suggest that reflective practice can contribute to the development of skilled, self-aware and engaged practitioners.

'I found the OSCE very stressful': student midwives' attitudes towards an objective structured clinical examination (OSCE).

BACKGROUND: The Objective Structured Clinical Examination (OSCE) has become widely accepted as a strategy for assessing clinical competence in nursing and midwifery education and training. There is a dearth of information, however, on the OSCE procedure from the perspective of midwifery students. In particular, there is an absence of an objective quantification of midwifery students' attitudes towards the OSCE. OBJECTIVES: The objective of this study is to report the conduct and findings of a survey of midwifery students' attitudes towards a Lactation and Infant Feeding OSCE and to consider these attitudes in the context of the international literature and the empirical evidence base. METHODS: A descriptive survey design using an 18-item Likert (1 to 5 point) scale was used to capture the relevant data. Potential participants were 3rd year midwifery students who had undertaken a Lactation and Infant Feeding OSCE (n=35) in one School of Nursing & Midwifery in the Republic of Ireland. Survey responses were analysed using the Statistical Package for the Social Sciences Version 18. RESULTS: Thirty-three students completed the survey providing a 94% response rate. Midwifery students' attitudes towards individual aspects of the OSCE varied. Overall, midwifery students were neutral/unsure of the OSCE as a strategy for assessing clinical competence (mean 3.3). Most agreed that the examiner made them feel at ease (mean 3.94). Contrastingly this does not appear to appease student nerves and stress as the majority agreed that the OSCE evokes nervousness (mean 4.27) and stress (mean 4.30). Midwifery students, overall, disagreed that the OSCE reflected real life clinical situations (mean 2.48). Midwifery students were neutral/unsure that the OSCE provided an opportunity to show their practical skills (mean 3.36). CONCLUSION: The findings of this study identified that midwifery students were neutral/unsure of the OSCE as a strategy for assessing clinical competence. This has relevance for OSCE development at the authors' institution. The results suggest the need to explore further why students responded in this way. This will assist to develop this OSCE further to ensure that it becomes a positive assessment process for midwifery students and for student learning as they progress through their midwifery education and training.

Group marking and peer assessment during a group poster presentation: the experiences and views of midwifery students.

Traditionally, written examination and clinical practice assessments are the main ways of deeming midwifery students fit and competent for practice. Contemporary academics in an effort to engage the students in the learning process have employed alternative teaching and assessment strategies. Among the alternative strategies are group projects after which members of the group are awarded the same grade, and peer assessment. With the purpose of informing the midwifery curricular, we utilised a qualitative descriptive approach to explore midwifery students' experiences and views on the use of group poster presentation for learning and assessment. The participants consisted of a purposive sample of 14 higher diploma midwifery students who were registered in a third level institution in Ireland. Semi-structured individual interviews were conducted following the completion of the poster presentation assessment. Permission to undertake the study was obtained from the college ethics committee. In this paper, we focus on the participants' views of group marking and peer assessment which are among the key elements that emerged in this study. While awarding a group mark was overall accepted, peer assessment proved a more contentious issue. Most of the participants found it challenging marking their friends. Reactions to group marks were very much influenced by the group dynamics.

The Objective Structured Clinical Examination (OSCE) as a strategy for assessing clinical competence in midwifery education in Ireland: a critical review.

In Ireland, to register as a midwife, all student midwives must be deemed competent to practice with the assessment of competence an essential component of midwifery education. A variety of assessment strategies, including observed practice, clinical interviews, portfolios of reflection, the Objective Structured Clinical Examination (OSCE) and written examination papers, are utilised to assess midwifery students' clinical competence. In this paper, a critical review of the OSCE as a strategy for assessing clinical competence in one third level institution in Ireland is offered. Although utilised for assessing competence across a range of areas (e.g. obstetric emergencies and pharmacology/drug administration), the use of the OSCE for assessing midwifery students' competence in lactation and infant feeding practices, as an example for this paper, is described. The advantages, disadvantages, validity and reliability of the OSCE, as an assessment strategy, are critically explored. Recognising that no single assessment strategy can provide all the information required to assess something as complex as clinical performance, the OSCE, when viewed alongside other forms of assessment, and with relevance to the topic under examination, may be considered a valuable strategy for enhancing the assessment of students' clinical competence, and for embracing diversity within midwifery education and training.