Coupling of fetal movement and fetal heart rate accelerations as an indicator of fetal health.

OBJECTIVE: The purpose of this study was to determine the clinical value of identified coupling of fetal heart rate (FHR) accelerations (more than five beats per minute for any duration) with objectively detected fetal movements. METHODS: One hundred sixty-six patients underwent routine fetal testing using a Doppler device that recognized both FHR and fetal movements. The coupling index was determined to be the percentage of fetal movements associated with FHR accelerations, and various coupling indices were compared with nonstress test (NST) results. RESULTS: A coupling index above 25% and below 75% compared well with the traditional NST by standard epidemiologic criteria and by the kappa statistic. CONCLUSION: Coupling of even small FHR accelerations and fetal movements could substitute for or replace the NST in antenatal screening.

Doppler recordings of fetal movement: II. Comparison with maternal perception.

Twenty-seven women were studied to assess the relationship between maternally perceived fetal movement and that recorded by a Doppler device. Eighty-eight percent (433 of 492) of maternally perceived movements were detected by Doppler, but only 16% of movements detected by Doppler were maternally perceived (433 of 2196). When complex movements were classified by duration, those movements lasting between 20-60 seconds were most likely (correlation greater than 0.9) to be perceived by the mother. This Doppler method has the potential to replace maternal event marking and other techniques in the recording of fetal movement.

A prospective comparison of hourly and quarter-hourly oxytocin dose increase intervals for the induction of labor at term.

Fifty-two women undergoing labor induction and vaginal delivery at term were randomized between two oxytocin infusion protocols, involving hourly versus quarter-hourly increases in dose. Potential differences were sought of duration of labor, amount of uterine activity generated, and amount of oxytocin required. Starting at 0.5 mU/minute, oxytocin infusion was increased regularly in small increments every hour or every 15 minutes, according to group assignment. No differences were observed in potentially confounding clinical and demographic factors between the groups, including time to ruptured membranes. There were no clinically or statistically significant differences found for the duration of any phase or stage of labor, quantitative assessment of uterine activity, incidence of hyperstimulation, or neonatal outcome. The average dose of oxytocin used was lower in the hourly than in the quarter-hourly, protocol (4.4 versus 6.7 mU/minute; P less than .005). Significantly fewer patients on the hourly protocol required a maximum infusion rate exceeding 8 mU/minute (P less than .05). More patients on the hourly protocol either had oxytocin discontinued completely or were maintained at 4 mU/minute or less during the active phase of labor (P less than .05 and P less than .001, respectively). We conclude that a slower rate of increase in oxytocin administration via continuous infusion results in no prolongation of any phase of induced labor, while permitting lower infusion rates of the drug.

State regulation, payment policies, and nurse-midwife services.

State regulatory and reimbursement policies continue to exert a strong influence on health workforce policy. Surveys conducted in 1991 and 1995 for the purpose of examining the impact of state regulation on the supply and practice of certified nurse-midwives (CNMs) showed that the single best predictor of the distribution and practice activities of CNMs was the degree to which state policies facilitated or restricted CNM practice.

Population differences affect nonstress test reactivity.

The nonstress test (NST) is the most widely used test of fetal well-being. Recently it has been suggested that race may play a role in NST reactivity. The objective of this research was to explore population variables in addition to race that may influence NST reactivity. Study subjects were 1263 black and 658 white women who underwent NST in the week preceding delivery at a tertiary facility. Retrospective analysis of data from a comprehensive database was conducted. It was found that the percentage of black women with a nonreactive NST was more than three times the percentage of white women, and that from 35 weeks' to 42 weeks' gestation there were significantly fewer reactive NSTs for blacks than for whites (P less than .05). Racial differences in NST results persisted in a logistic regression analysis controlling for several population variables including pregnancy complications and demographic and behavioral factors (odds ratio 3.81; 95% CI 3.03 to 4.78). Regression analysis also confirmed that gestational age, maternal education, epilepsy, and smoking significantly influenced NST reactivity. These results indicate that population differences in NST reactivity exist at our facility. Further prospective study of population determinants of NST reactivity is needed to determine how race, test indication, and other clinical, demographic, and behavioral variables should be used in interpretation of tests of fetal well-being. Standard criteria for NST testing may not be useful in all obstetrical populations.

Trends in selected obstetric complications from University Hospital, Kuala Lumpur, Malaysia.

Trends in selected pregnancy complications from 1969 to 1987 in a tertiary hospital in Malaysia are presented. Complications reviewed were abortion, ectopic pregnancy, anemia, hypertension, hyperemesis, antepartum and postpartum hemorrhage. Possible explanations for the observed trends were discussed, including the role of improved obstetric care and changes in the characteristics of the childbearing population. The data presented give some indication of maternal morbidity in the childbearing population served by this tertiary center and should lead to improvements in provision of services as well as in health data collection in the future.

The association of childhood sexual abuse with depressive symptoms during pregnancy, and selected pregnancy outcomes.

OBJECTIVES: The objectives were: (1) to investigate the association during pregnancy of sexual abuse before the age of 18 on depressive symptomatology in pregnancy, controlling for the presence of negative life events and challenges; and (2) to investigate the association of selected pregnancy outcomes (maternal labor and delivery factors, infant birth weight and gestational age) with sexual abuse before age 18. METHODS: Three hundred fifty-seven primiparous women aged 18 years and older were interviewed between 28-32 weeks gestation with reference to current functioning and past history (Objective 1). Medical record information was abstracted after delivery for pregnancy, labor and delivery factors, and pregnancy outcomes (Objective 2). RESULTS: Thirty-seven percent of the women reported past sexual abuse. Prevalence was not associated with ethnic background, educational level, or hospital payment source. Previously sexually-abused pregnant women reported significantly higher levels of depressive symptomatology, negative life events, and physical and verbal abuse before and during pregnancy. There were no significant associations found between past sexual abuse and labor or delivery variables or newborn outcomes. CONCLUSIONS: Previously sexually-abused pregnant women reported a wider constellation of past and current functioning problems than nonabused women although past sexual abuse was not associated with pregnancy outcome. Prenatal care provides a unique opportunity to evaluate the impact of life history and current life events during pregnancy, and to develop a coordinated intervention plan.

Interpretation of biophysical profiles by nurses and physicians.

OBJECTIVE: To determine the agreement between nurse and physician interpretation of biophysical profile scores. DESIGN: A prospective evaluation of videotaped biophysical profiles was independently scored by four nurse and four physician interpreters and compared to that of an expert physician. SETTING: The fetal assessment center of a large tertiary-care center; study included women from public and private practices. PATIENTS: Twenty-three women with high-risk pregnancies who were regularly scheduled for a biophysical profile. Women pregnant with multiple fetuses or whose fetuses were less than 28 weeks' gestational age or had severe fetal anomalies were excluded. MAIN OUTCOME MEASURE: The proportion of agreement between the physicians and nurses and the physician expert was calculated for each biophysical profile criterion. RESULTS: The kappa statistic was used to evaluate the proportion of agreement with the "gold standard." When compared with the expert, physicians showed 60% moderate or substantial agreement, and the nurses showed 80% moderate or substantial agreement. CONCLUSIONS: Nurses' interpretations of biophysical profiles were at least as reliable as physicians' when compared with an expert reviewer.

A comparison of two time intervals for the ausculated acceleration test.

OBJECTIVE: Interest in an inexpensive, easy-to-administer antenatal screening test that did not rely on the use of electronic fetal monitoring led to development of the fetoscope administered auscultated acceleration test (AAT) in the late 1980s. More recent efforts have been directed toward providing those who may use the AAT with important information about the most effective and clinically appropriate AAT procedures. The purpose of this study was to determine the screening test validity performance of two AAT time intervals--6 minutes and 10 minutes. METHODS: Two auscultated acceleration tests (AAT6 and AAT10) were simultaneously performed using different time intervals on 205 women with high-risk pregnancies undergoing simultaneous nonstress tests (NSTS) who were referred to a tertiary care unit for antepartum testing. Standard measurements of screening test validity were calculated for each test in the prediction of selected perinatal outcomes. NST findings were included for comparative purposes. RESULTS: The AAT6 yielded an overall higher specificity as compared with the AAT10 at the expense of a slightly lower sensitivity for most perinatal outcomes; these differences were not significant at the .05 level. Relative risk ratios were similar for the AAT6 and AAT10 for both fetal distress and neonatal morbidity, with both AAT being a more effective predictor of neonatal morbidity than for fetal distress. Both tests yielded better sensitivity when compared with NST. CONCLUSIONS: Even though there was a nonsignificant trend toward higher sensitivities and lower specificities for the 10-minute AAT, this study showed that the differences in prediction of perinatal outcomes between the 6-minute and 10-minute AAT were minimal. In view of the added labor required for the 10-minute AAT in the absence of enhanced screening test validity, the 6-minute AAT is clinically preferred. This study has prompted new research questions for the continued development of the AAT as a low-technology fetal assessment technique with potential usefulness by midwives and their colleagues in a variety of settings worldwide.

A comparison of visits and practices of nurse-midwives and obstetrician-gynecologists in ambulatory care settings.

With more than 5 million patient visits annually, certified nurse-midwives (CNMs) substantially contribute to women's health care in the United States. The objective of this study was to describe ambulatory visits and practices of CNMs, and compare them with those of obstetrician-gynecologists (OB/GYNs). Sources of population-based data used to compare characteristics of provider visits were three national surveys of CNMs and two National Ambulatory Medical Care Surveys of physicians. When a subset of 4,305 visits to CNMs in 1991 and 1992 were compared to 5,473 visits to OB/GYNs in similar office-based ambulatory care settings in 1989 and 1990, it was found that a larger proportion of CNM visits were made by women who were publicly insured and below age 25. The majority of visits to CNMs were for maternity care; the majority of visits to OB/GYNs were for gynecologic and/or family planning concerns. Face-to-face visit time was longer for CNMs, and involved more client education or counseling. This population-based comparison suggests that CNMs and OB/GYNs provide ambulatory care for women with diverse demographic characteristics and differing clinical service needs. Enhancing collaborative practice could improve health care access for women, which would be especially beneficial for those who are underserved and vulnerable.

Serving women in need: nurse-midwifery practice in the United States.

OBJECTIVE: Nurse-midwifery practices in the United States were examined to study the relationship between certified nurse-midwives' (CNMs) demographic, work setting, and practice characteristics in terms of clientele, practice size, and practice type. Factors that might influence the ability of CNMs to serve populations at risk for poor outcomes were given particular attention. METHODOLOGY: A total of 2,405 responses to a 1998 mailed survey of 6,365 nurse-midwives ever-certified by the American College of Nurse-Midwives were analyzed. RESULTS: Study results indicated that CNMs continue to serve a population who are, based on a social risk profile, disproportionately at risk for poor pregnancy outcomes, including women who are uninsured (16%), immigrant (27%), adolescent (29%), and women of color (50%). It was also found that clientele varied according to practice settings: CNMs working in non-hospital, nonprofit settings served a clientele that was 65% nonwhite, 44% immigrant, 40% adolescent, and 29% uninsured; these CNMs received 61% of their client payments from Medicaid. CNMs working in private offices or for managed care organizations were less likely to serve women with these characteristics. CONCLUSION: Study results, taken in conjunction with research that documents the safety of nurse-midwifery practice, reinforce policy recommendations that support expanded access to nurse-midwifery services. Findings also indicate a need for further research in the areas of CNM workload and productivity in managed care settings and the association between CNM race and ethnicity and the race and ethnicity of their clients.

Midwifery education and research in the future.

This paper is adapted from a plenary lecture presented at the 22nd International Congress, International Confederation of Midwives, Kobe, Japan, October 11, 1990. Midwifery education and research in the past, present, and future are discussed. Special emphasis is placed on innovation in midwifery education to address more adequately the worldwide concern about safe motherhood. Midwifery research and the integral components of information and inquiry are also discussed, with emphasis on five major areas in need of further research. Collaborative education and research are explored from both an interdisciplinary and an international perspective.

Trends in nurse-midwifery. Results of the 1988 ACNM Division of Research Mini-Survey.

The purpose of the 1988 Mini-Survey was the collection of up-to-date data from the ACNM membership, focusing on nurse-midwifery income. These were the last data collected about CNMs for the 1980 decade. The final survey sample included 1,735 CNMs and 67 SNMs; 70.6% of the CNMs were in clinical practice. The demographic, employment, and income findings are presented for all CNM respondents by ACNM region of residence and for CNMs in full-scope clinical nurse-midwifery practice. Additional income findings for CNMs working full time and part time are also presented by ACNM region of residence, as well as by selected individual states. Nurse-midwifery income is compared with nursing income during the same time period. Demographic and/or employment characteristics are presented for CNMs doing home births, for student nurse-midwives, for nurse-midwifery faculty, and for nurse-midwives with doctorates. In surveys done from 1984 to 1988, the mean full-time CNM annual income increased by +10,000. The 1988 Survey data are now approximately two years old and the impact of the recent nursing shortage on both nursing and nurse-midwifery salaries was not necessarily reflected in these data.

Psychopharmacologic management of women with common mental health problems.

This article reviews the essential aspects of the psychopharmacologic management of women with mental health problems, with particular emphasis on the role of the nurse-midwife as a primary care provider. The article also addresses the neurobiology of psychopharmacology, pharmacokinetics, and the selection of pharmacologic treatments used for depression, bipolar disorders, anxiety disorders, eating disorders, and psychosis. Considerations for the timely and appropriate referral for psychiatric intervention for women with psychiatric or pharmacologic emergencies are discussed, and issues relating to pregnancy, lactation, and reproductive health are included. The importance of the nurse-midwife's role in ensuring women's access to and compliance with psychopharmacologic therapy is emphasized.

Nurse-midwives speak out on research. Results of the 1987-88 needs assessment survey, Part 2.

Part 1 of this 2 part article appeared in the preceding (January/February) issue of this journal. Results from the 1987-88 ACNM Needs Assessment Survey pertaining to research are presented. As with other topics addressed in Part 1 of the Needs Assessment Survey, subgroup analysis was conducted to determine if certain groups of CNMs had differing views and perceived needs regarding research. Survey responses were categorized to include: 1) CNM attitudes about research, 2) importance of ACNM research related services and activities, 3) use of a uniform data collection instrument, 4) CNM access to research resources, and 5) views on funding for ACNM research activities. Discussion of the implications of the results as they relate to development of the goals and objectives of the newly formed ACNM Division of Research is included.

The effect of maternal bearing-down efforts on arterial umbilical cord pH and length of the second stage of labor.

This study was conducted to compare two types of maternal bearing-down techniques as they relate to the fetal and maternal outcomes of arterial umbilical cord blood pH and length of the second stage of labor. A convenience sample was drawn from the laboring women at a 305-bed medical center who met specific inclusion criteria. Women self-selected to one of two bearing-down groups: spontaneous or Valsalva. Subjects were given specific instructions for the chosen method. The Valsalva group was comprised of 14 subjects, and the spontaneous group was comprised of 16 subjects. The groups were found to be comparable after analysis of several variables. Results of statistical analysis using t-test indicated that, in this small sample, there is no relationship between the second stage bearing-down method and arterial umbilical cord blood pH or length of the second stage of labor. These findings support the conclusions of several studies: using the spontaneous bearing-down method does not have a deleterious effect upon the mother or the fetus. Several recommendations are made for future research based on methodological issues raised during this study.