Cultivating Resilience Among Perinatal Care Providers During the Covid-19 Pandemic.

The Covid-19 pandemic has further illuminated the already existing need for methods of building resilience in perinatal caregivers. Using a scoping review approach, literature was examined to identify evidence-based models of resilience building in a cohort of perinatal clinicians. Research published between January 2015 and 2020 was evaluated using PubMed, CINAHL, EMBASE, and PsycINFO databases. Of the initial 3399 records reviewed, 2 qualitative studies met the inclusion criteria. Given the deleterious effects of Covid-19 on perinatal care providers, and in light of the paucity of available studies, personnel, time, and funding should be allocated for research to address these issues.

Identifying optimal labor and delivery nurse staffing: The case of cesarean births and nursing hours.

BACKGROUND: Numerous studies have identified a relationship between nurse staffing and adverse patient outcomes in medical / surgical patient populations. However, little is known about the impact of labor and delivery (L&D) nurse staffing and adverse birth outcomes, such as unintended cesarean delivery, in low-risk term-gestation women. PURPOSE: We examined nurse staffing patterns on the likelihood of cesarean sections (C-sections) among low- risk, full gestation births and provided a testing framework to distinguish optimal from ineffective levels of nurse staffing. METHODS: This retrospective descriptive study used hours of productive nursing time per delivery as the treatment variable to determine direct nursing time per delivery and its impact on the likelihood of a C-section. For comparisons, we also assessed the likelihood of augmentations and of inductions, as well as the number of neonatal intensive care unit (NICU) hours per birth. We limited our sample to those births between 37 and 42 weeks of gestation. Two complimentary models (the quadratic and piecewise regressions) distinguishing optimal staffing patterns from ineffective staffing patterns were developed. The study was implemented in eleven hospitals that are part of a large, integrated healthcare system in the Southwest. DISCUSSION: While a simple linear regression of the likelihood of a C-section on nursing hours per delivery indicated no statistically distinguishable effect, our 'optimal staffing' model indicated that nurse staffing hours employed by using a large sample of hospitals were actually minimizing C-sections (robustness checks are provided using similar model comparisons for the likelihood of augmentation and induction, and NICU hours). Where the optimal staffing models did not appear to be effective for augmentations, inductions, and NICU hours, we found significant differences between facilities (i.e., significant fixed effects for hospitals). In all specifications, we also controlled for weeks of gestation, race, sex of the child, and mother's age.

Randomized comparison of a reduced-visit prenatal care model enhanced with remote monitoring.

BACKGROUND: Standard prenatal care, consisting of 12-14 visits per pregnancy, is expensive and resource intensive, with limited evidence supporting the structure, rhythm, or components of care. Some studies suggest a reduced-frequency prenatal care model is as safe as the standard model of care for low-risk pregnant women, but evidence is limited. We developed and evaluated an innovative, technology-enhanced, reduced prenatal visit model (OB Nest). OBJECTIVE: To evaluate the acceptability and effectiveness of OB Nest, a reduced-frequency prenatal care model enhanced with remote home monitoring devices and nursing support. STUDY DESIGN: A single-center randomized controlled trial, composed of pregnant women, aged 18-36 years, recruited from an outpatient obstetric tertiary academic center in the Midwest United States. OB Nest care consisted of 8 onsite appointments with an obstetric provider; 6 virtual visits consisting of phone or online communication with an assigned nurse, supplemented with fetal Doppler and sphygmomanometer home monitoring devices; and access to an online community of pregnant women. Usual care consisted of 12 prescheduled prenatal clinic appointments with obstetric providers. Acceptability of OB Nest was measured by validated surveys of patient satisfaction with care at 36 weeks; perception of stress at 14, 24, and 36 weeks; and perceived quality of care at 36 weeks of gestation. Effectiveness was analyzed by comparing adherence to the American College of Obstetricians and Gynecologists recommended routine prenatal and ancillary services, maternal and fetal safety outcomes, and healthcare utilization. RESULTS: Three hundred pregnant women at <13 weeks of gestation were recruited and randomized to OB Nest or usual care (150 in each arm) using a minimization algorithm. Demographic characteristics were similar between groups. Compared to usual care, patients in OB Nest had higher satisfaction on a 100-point validated modified Littlefield and Adams Satisfaction scale (OB Nest = 93.9% vs usual care = 78.9%, P < .01). Pregnancy-related stress, measured, on a 0-2 point PreNatal Maternal Stress validated scale, with higher scores indicating higher levels of stress, was lower among OB Nest participants at 14 weeks (OB Nest = 0.32 vs usual care = 0.41, P < .01) and at 36 weeks of gestation (OB Nest = 0.34 vs usual care = 0.40, P < .03). There was no statistical difference in perceived quality of care. Adherence to the provision of American College of Obstetricians and Gynecologists prenatal services was similar in both arms. Maternal and fetal clinical outcomes were similar between groups. Total reported nursing time was higher in OB Nest (OB Nest = 171.2 minutes vs usual care = 108.2 minutes, 95% confidence interval, 48.7-77.4). CONCLUSION: OB Nest is an innovative, acceptable, and effective reduced-frequency prenatal care model. Compared to routine prenatal care, OB Nest resulted in higher patient satisfaction and lower prenatal stress, while reducing the number of appointments with clinicians and maintaining care standards for pregnant women. This program is a step toward evidence-driven prenatal care that improves patient satisfaction.

Impact of a peer virtual community on pregnant women's well-being: A repeated-measure and quasi-experimental study.

AIM: To investigate the effects of a virtual community on pregnant women's well-being. BACKGROUND: The virtual social network has been growing rapidly but its effects remain unclear. DESIGN: A repeated-measure and quasi-experimental study. METHODS: We designed a closed Facebook community for peer-to-peer interaction with no mediator. A total of 121 pregnant women were assigned to either experimental or control group. Data were collected from May 2012-January 2015 using five instruments related to pregnant women's well-being. RESULTS: Significant differences on pregnant women's well-being were not found between groups. However, higher adherence to the virtual community was significantly related to first-time pregnant women and women whose pregnancy was assisted by a technology treatment. CONCLUSIONS: Nurses and midwifes are recommended to pay more attentions on first-time pregnant women and women whose pregnancy was assisted by a technology treatment regarding their pregnancy-related concerns. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT03692923.

Maternity and postpartum care: perspectives.

EBN Perspectives brings together key issues from the commentaries in one of our nursing topic themes.

Evaluation of the mobile nurse training (MNT) intervention - a step towards improvement in intrapartum practices in Bihar, India.

BACKGROUND: Evidence shows that improving the quality of intrapartum care is critical for maternal survival. However, a significant rise in the proportion of facility-based births over the last decade in India - attributable to a cash transfer program - has not resulted in a corresponding reduction in maternal mortality, thanks, in part, to low-skilled care at facilities. The current study evaluated a mobile knowledge-based intervention aimed at improving quality of care by mentoring in-service staff nurses at public obstetric facilities. METHODS: An independent evaluation team conducted baseline and post-intervention assessments at every facility using a mix of methods that included training assessments and Direct Observation of Deliveries. The assessment involved passive observation of pregnant women from the time of their admission at the facility and recording the obstetric events and delivery-related practices on a pre-formatted checklist-based tool. Maternal practices were classified into positive and negative ones and scored. Linear regression analysis was used to evaluate the association of MNT intervention with summary scores for positive, negative and overall practice scores. We evaluated retention of intervention effect by comparing the summary scores at baseline, immediately following intervention and 1 year after intervention. RESULTS: In both unadjusted and adjusted analyses, the intervention was found to be significantly associated with improvement in positive practice score (Unadjusted: parameter estimate (ß) = 16.90; 95% confidence interval (CI) = 15.20, 18.60. Adjusted: ß = 13.14; 95% CI = 10.97, 15.32). The intervention was also significantly associated with changes in negative practice score, which was reverse coded to represent positive change (Unadjusted: ß = 11.66; 95% CI = 10.06, 13.27. Adjusted: ß = 2.99; 95% CI = 1.35, 4.63), and overall practice score (Unadjusted: ß = 15.74; 95% CI = 14.39, 17.08; Adjusted: ß = 10.89; 95% CI = 9.18, 12.60). One year after the intervention, negative practices continued to improve, albeit at a slower rate; positive labor practices and overall labor practice remained higher than the baseline but with some decline over time. CONCLUSIONS: Findings suggest that in low resource settings, interventions to strengthen quality of human resources and care through mentoring works to improve intrapartum maternal care.

The Perinatal Birth Environment: Communication Strategies and Processes for Adherence to a Standardized Guideline in Women Undergoing Second-Stage Labor With Epidural Anesthesia.

Key to any perinatal safety initiative is buy-in and strong leadership from obstetric and pediatric providers, advanced practice nurses, and labor and delivery nurses in collaboration with ancillary staff. In the fall of 2007, executives of a large Midwestern hospital system created the Zero Birth Injury Initiative. This multidisciplinary group sought to eliminate birth injury using the Institute of Healthcare Improvement Perinatal Bundles. Concurrently, the team implemented a standardized second-stage labor guideline for women who choose epidural analgesia for pain management to continue the work of eliminating birth injuries in second-stage labor. The purpose of this article was to describe the process of the modification and adaptation of a standardized second-stage labor guideline, as well as adherence rates of these guidelines into clinical practice. Prior to implementation, a Web-based needs assessment survey of providers was conducted. Most (77% of 180 respondents) believed there was a need for an evidence-based guideline to manage the second stage of labor. The guideline was implemented at 5 community hospitals and 1 academic health center. Data were prospectively collected during a 3-month period for adherence assessment at 1 community hospital and 1 academic health center. Providers adhered to the guideline in about 57% of births. Of patients whose provider followed the guideline, 75% of women were encouraged to delay pushing compared with only 28% of patients delayed pushing when the provider did not follow the guideline.

Testing the Effectiveness of Therapeutic Showering in Labor.

: Therapeutic showering is a holistic nursing intervention that is often available and supports physiologic labor. The purpose of this study was to compare the effectiveness of therapeutic showering with usual care during active labor. Research questions were as follows: Are there significant differences between women who showered 30 minutes during active labor and those who received usual labor care in anxiety, tension, relaxation, pain, discomfort, and coping? Is there a difference in use of obstetric interventions between groups? A convenience sample of healthy low-risk women in active labor was recruited (N = 32). A pretest posttest control group repeated-measures design was used. Participants were randomized to treatment group (n = 17), who showered for 30 minutes, or to control group (n = 14) who received usual labor care. Women evaluated pain, discomfort, anxiety, tension, coping, and relaxation at enrollment, again 15 minutes after entering the shower or receiving usual care, then again 30 minutes after entering the shower or receiving usual care. Chart reviews after delivery recorded obstetric interventions. The showering group had statistically significant decreases in pain, discomfort, anxiety and tension, and significant increase in relaxation. There were no differences in use of obstetric interventions. Therapeutic showering was effective in reducing pain, discomfort, anxiety, and tension while improving relaxation and supporting labor in this sample.

The experience of Italian nurses and midwives in the termination of pregnancy: a qualitative study.

OBJECTIVES: The aim of the study was to provide insight into the experiences of nurses and midwives working in the Italian abortion service. METHODS: Study participants were recruited through purposive sampling. Semi-structured interviews were conducted between July and September 2016, among 22 nurses and two midwives working in five abortion services in Milan, Italy. Transcripts of interviews were analysed using a phenomenological approach to data analysis. RESULTS: Five main themes emerged from the analysis: (a) coping with caring for women undergoing a termination of pregnancy; (b) improving professional training; (c) approaching work in a mechanistic way as a means of overcoming difficulties; (4) performing medical abortions; (d) recounting an experience. CONCLUSIONS: This first study about assisting with pregnancy termination in Italy may enable critical comparison with studies carried out in other countries. Both nurses and midwives suggested strategies, which may improve the provision of care: collaboration between primary and tertiary care, continuous training, multidisciplinary collaboration, increase of staff turnover and being kept abreast of new pharmaceutical products. Our findings are applicable to wider medical practice.

Implementation of the WHO safe childbirth checklist program at a tertiary care setting in Sri Lanka: a developing country experience.

BACKGROUND: To study institutionalization of the World Health Organization's Safe Childbirth Checklist (SCC) in a tertiary care center in Sri Lanka. METHOD: A hospital-based, prospective observational study was conducted in the De Soysa Hospital for Women, Colombo, Sri Lanka. Healthcare workers were educated regarding the SCC, which was to be used for each woman admitted to the labor room during the study period. A qualitatively pretested, self-administered questionnaire was given to all nursing and midwifery staff to assess knowledge and attitudes towards the checklist. Each item of the SCC was reviewed for adherence. RESULTS: A total of 824 births in which the checklist used were studied. There were a total of births 1800 during the period, giving an adoption rate of 45.8%. Out of the 170 health workers in the hospital (nurses, midwives and nurse midwives) 98 answered the questionnaire (response rate = 57.6%). The average number of childbirth practices checked in the checklist was 21 out of 29 (95% CI 20.2, 21.3). Educating the mother to seek help during labor, after delivery and after discharge from hospital, seeking an assistant during labor, early breast-feeding, maternal HIV infection and discussing contraceptive options were checked least often. The mean level of knowledge on the checklist among health workers was 60.1% (95% CI 57.2, 63.1). Attitudes for acceptance of using the checklist were satisfactory. Average adherence to checklist practices was 71.3%. Sixty eight (69.4%) agreed that the Checklist stimulates inter-personal communication and teamwork. Increased workload, poor enthusiasm of health workers towards new additions to their routine schedule and level of user-friendliness of Checklist were limitations to its greater use. CONCLUSIONS: Amongst users, the attitude towards the checklist was satisfactory. Adoption rate amongst all workers was 45.8% and knowledge regarding the checklist was 60.1%. These two factors are probably linked. Therefore prior to introducing it to a facility awareness about the value and correct use of the SCC needs to be increased, while giving attention to satisfactory staffing levels.

Reliability and validity of an instrument to measure the beliefs of intrapartum nurses.

Intrapartum nurses assume a central role in the birth process and make decisions driven by a set of beliefs. Therefore, the purpose of this study was to develop a valid and reliable instrument to measure birth beliefs of intrapartum nurses related to birth practice. A total of 313 intrapartum nurses accessed this online, self-administered instrument over a 3-month period. The Theory of Planned Behavior guided development of the Intrapartum Nurses' Beliefs Related to Birth Practice scale and provided a basis for the connection between beliefs and practice. This article describes the psychometric analysis of the instrument. Findings include a moderate, positive correlation with a similar instrument, a Cronbach α of 0.797, and 2 factors identifying belief systems. With further revision, this instrument may provide an accurate measure of the birth beliefs of intrapartum nurses.

Development and testing of the Preeclampsia Prenatal Symptom-Monitoring Checklist (PPSMC).

BACKGROUND AND PURPOSE: Preeclampsia, a common disorder of unknown origin, presents with signs and symptoms that can be subtle, making assessment and intervention challenging. The purpose of this study was to refine the psychometric properties of an instrument designed to assess a comprehensive range of preeclampsia symptoms. METHODS: Testing of the Preeclampsia Prenatal Symptom-Monitoring Scale (PPSMC) was accomplished through a retrospective, correlational, and comparative study of 100 postpartum women with preeclampsia and gestational hypertension. RESULTS: The initial 17-item Cronbach's alpha was .73; reliability of the current 11-item PPSMC increased to .77. Content validity index for the PPSMC (17 items) was .88; for the PPSMC (11 items), .93. Exploratory factor analysis, known group comparisons, and predictive validity lend beginning support of the instrument's construct validity. CONCLUSION: This instrument may be useful in examining in greater detail the symptomatology of women with preeclampsia in practice and research settings.

Evidence-based stillbirth prevention strategies: combining empirical and theoretical paradigms to inform health planning and decision-making.

INTRODUCTION: A global health project undertaken in Qatar on the Arabian Peninsula immersed undergraduate nursing students in hands-on learning to address the question: What strategies are effective in preventing stillbirth? Worldwide stillbirth estimates of 2.6 million per year and the high rate in the Eastern Mediterranean Region of 27 per 1,000 total live births provided the stimulus for this inquiry. METHODS: We used a dual empirical and theoretical approach that combined the principles of evidence-based practice and population health planning. Students were assisted to translate pre-appraised literature based on the 6S hierarchical pyramid of evidence. The PRECEDE-PROCEED (P-P) model served as an organizing template to assemble data extracted from the appraisal of 21 systematic literature reviews ± meta-analyses, 2 synopses of synthesized reports, and 9 individual studies summarizing stillbirth prevention strategies in low, middle, and high income countries. Consistent with elements of the P-P model, stillbirth prevention strategies were classified as social, epidemiological, educational, ecological, administrative, or policy. RESULTS: Ten recommendations with clear evidence of effectiveness in preventing stillbirth in low, middle, or high income countries were identified. Several other promising interventions were identified with weak, uncertain, or inconclusive evidence. These require further rigorous testing. LINKING EVIDENCE TO ACTION: Two complementary paradigms--evidence-based practice and an ecological population health program planning model--helped baccalaureate nursing students transfer research evidence into useable knowledge for practice. They learned the importance of comprehensive assessments and evidence-informed interventions. The multidimensional elements of the P-P model sensitized students to the complex interrelated factors influencing stillbirth and its prevention.

Validation of an instrument for patient classification to support obstetric nursing care.

OBJECTIVES: to develop and validate an instrument for the classification of pregnant and postpartum women according to the demand for nursing care. METHODS: a methodological study conducted in three stages: 1) construction of the instrument based on literature review; 2) content validation using the Delphi technique with 12 experts; and 3) Evaluation of the convergent construct validity through the correlation between the scores of the constructed instrument and the Fugulin instrument. RESULTS: an instrument with ten indicators of specific care for pregnant and postpartum women was developed. A content validity index higher than 0.9 was obtained, requiring only one round of the Delphi technique. The Spearman coefficient was 0.64 between the instruments, indicating a strong correlation. CONCLUSIONS: the classification instrument specifically constructed for pregnant and postpartum women showed evidence of content validity and convergent construct validity with a widely used instrument in the national territory.

Support Needs of Labor and Delivery Nurses After Traumatic Experiences.

OBJECTIVE: To examine the effect of psychological distress, overall distress, and institutional support following a traumatic workplace event on absenteeism, turnover intention, and resilience among labor and delivery nurses. DESIGN: A quantitative cross-sectional survey. SETTING: Online distribution from January 13, 2021, to February 2, 2021. PARTICIPANTS: A nationwide convenience sample of labor and delivery nurses recruited from the Association of Women's Health, Obstetric and Neonatal Nurses (N = 171). METHODS: Participants completed a survey that included the Second Victim Experience and Support Tool-Revised and the Second Victim Support Desirability survey. We compared available versus desired support options using descriptive analyses. We examined levels of psychological distress and lack of institutional support in relation to turnover intention, absenteeism, and resilience using multiple regression analyses. RESULTS: Participants identified and described various traumatic experiences in the workplace, including neonatal and maternal death, complicated births, and workplace violence. Participants indicated that the available support services did not meet their needs. Psychological distress, overall distress, and lack of institutional support were associated with absenteeism and turnover, whereas only institutional support was associated with resilience. CONCLUSION: Labor and delivery nurses encounter various traumatic events in the workplace, and the support services provided after an event do not meet their needs. Additional research is needed to understand the scope of the problem and investigate best practices to assist labor and delivery nurses following traumatic events.

Relationships Among Individual and Hospital Characteristics and Self-Efficacy in Labor Support Among Intrapartum Nurses in Texas.

OBJECTIVE: To explore the relationships among individual and workplace characteristics and self-efficacy in labor support among intrapartum nurses. DESIGN: Cross-sectional survey. SETTING: Online distribution from April to August 2020. PARTICIPANTS: Members of the Texas section of the Association for Women's Health, Obstetric, and Neonatal Nurses (N = 106). METHODS: I conducted descriptive analysis on individual and workplace characteristics, including scores on the Self-Efficacy Labor Support Scale. I conducted backward stepwise multivariate linear regression to assess the factors associated with self-efficacy in providing labor support. RESULTS: Years as an intrapartum nurse had a positive association with self-efficacy in labor support. Experience with open-glottis pushing, the overall cesarean birth rate, and the use of upright positioning during labor and birth were also positively associated with self-efficacy in labor support. Conversely, lack of recognition by providers was negatively associated with self-efficacy in labor support. CONCLUSION: Findings suggest that modifiable factors at the individual and hospital levels are associated with nurses' self-efficacy in labor support. Hospitals must work to engage in obstetric practices that are congruent with providing labor support, including the use of experienced nurses to mentor new nurses and the creation of a unit culture to reinforce the intent of individual nurses to provide labor support.

Achieving the millennium development goal of reducing maternal mortality in rural Africa: an experience from Burundi.

OBJECTIVES: To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Médecins Sans Frontières (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality. METHODS: The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi. RESULTS: In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55-99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8-360) deaths/100,000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100,000 live births). CONCLUSION: Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa.

Effect of nursing intervention program using abdominal palpation of Leopold's maneuvers on maternal-fetal attachment.

BACKGROUND: The aim of this study was to investigate whether a nursing intervention program using abdominal palpation would improve maternal-fetal relationships of pregnant women. METHODS: The subjects were Japanese women aged less than 40 years with singleton pregnancies. A nursing intervention involving abdominal palpations of Leopold's Maneuvers was performed for the intervention group (n = 35) in the 30th, 32nd, and 34th weeks' gestation, while ordinary health-related advice was provided to the control group (n = 73) in the corresponding period. RESULTS: At the 30th (baseline) week, no intergroup differences were observed. However, the intervention group showed higher Prenatal Attachment Inventory (PAI) scores in the 34th (P < 0.01) and 36th weeks (P < 0.05) as well as a higher frequency of talking to the fetus in the 32nd (P < 0.01), 34th (P < 0.01), and 36th weeks (P < 0.05). Furthermore, Fetal position awareness score in the 32nd, the 34th, and the 36th weeks were higher in the intervention group than in the control group (P < 0.001). CONCLUSIONS: The present findings have suggested that nursing interventions involving abdominal palpations can develop the maternal-fetal relationship. Further random controlled trials are warranted to ascertain this observation.

Professionals' views of fetal monitoring during labour: a systematic review and thematic analysis.

BACKGROUND: Current recommendations do not support the use of continuous electronic fetal monitoring (EFM) for low risk women during labour, yet EFM remains widespread in clinical practice. Consideration of the views, perspectives and experiences of individuals directly concerned with EFM application may be beneficial for identifying barriers to and facilitators for implementing evidence-based maternity care. The aim of this paper is to offer insight and understanding, through systematic review and thematic analysis, of research into professionals' views on fetal heart rate monitoring during labour. METHODS: Any study whose aim was to explore professional views of fetal monitoring during labour was considered eligible for inclusion. The electronic databases of MEDLINE (1966-2010), CINAHL (1980-2010), EMBASE (1974-2010) and Maternity and Infant Care: MIDIRS (1971-2010) were searched in January 2010 and an updated search was performed in March 2012. Quality appraisal of each included study was performed. Data extraction tables were developed to collect data. Data synthesis was by thematic analysis. RESULTS: Eleven studies, including 1,194 participants, were identified and included in this review. Four themes emerged from the data: 1) reassurance, 2) technology, 3) communication/education and 4) midwife by proxy. CONCLUSION: This systematic review and thematic analysis offers insight into some of the views of professionals on fetal monitoring during labour. It provides evidence for the continuing use of EFM when caring for low-risk women, contrary to current research evidence. Further research to ascertain how some of these views might be addressed to ensure the provision of evidence-based care for women and their babies is recommended.