Best Practices for Telehealth in Nurse-Led Care Settings-A Qualitative Study.

The COVID-19 pandemic in the US prompted a sudden shift to telehealth in nurse-led care sites which provide services to diverse geolocations. Using a lens of intersectionality, this study characterizes provider and patient-perceived best and promising practices emerging from geographical variation. The aim of this study was to identify best practices of implementing telehealth in nurse-led care models in Colorado through patient and provider experiences of the sudden implementation of telehealth that can enhance health equity. In this exploratory/descriptive qualitative study, a purposive sample of 18 providers and 30 patients were interviewed using a guide informed by the RE-AIM implementation and evaluation framework to capture the contextual experiences related to the sudden shift to telehealth. Textual theme analysis and reflexive team strategies guided the interpretation. Four primary themes of perceived best practices were identified: using multiple modalities, tailoring triage and scheduling, cultivating safety through boundaries and expectations, and differentiating established versus new patient relationships. The findings suggest that telehealth is a flexible and powerful tool to enhance the delivery of equitable care through nurse-led care models within diverse communities such as the one represented in this study. Nurse leaders are positioned to participate in innovative research and create policies and protocols to ensure telehealth is a viable resource to deliver equitable, safe, and accessible high-quality healthcare.

Perinatal Telehealth: Meeting Patients Where They Are.

INTRODUCTION: Prior to the coronavirus disease 2019 (COVID-19) pandemic, studies of innovative telehealth perinatal care models showed similar clinical outcomes and perceived quality of care between groups receiving a combination of virtual video and in-person visits. However, these studies included primarily White, English-speaking participants, excluding those who were economically disenfranchised or did not speak English. The purpose of this qualitative study was to describe perinatal patients' and providers' experiences with telehealth during and after the acute phase of the COVID-19 pandemic to inform future utilization of telehealth to drive the delivery of high-quality, accessible, and equitable perinatal care to diverse communities. METHODS: This descriptive qualitative study included a purposive sample of 14 patients and 17 providers who received or provided perinatal care via telehealth in either a certified nurse-midwifery practice or the nurse-family partnership care model between March 2020 and April 2022. Maximum variation sampling offered a diverse population based on race, ethnicity, and rurality. Researchers conducted 2 rounds of semistructured interviews with a focus on understanding social and geographic context. RESULTS: Six themes were identified through inductive analysis: (1) unexpected advantages of telehealth, (2) patient empowerment, (3) providers' fear of adverse outcomes, (4) concern for equitable care, (5) strategies to enhance the telehealth experience, and (6) strategies to address access to perinatal telehealth. Patients appreciated the increased ease and reduced cost of accessing visits, which led to fewer missed appointments. Health care providers saw great opportunity in telehealth but expressed concerns about accessibility for patients with language barriers or limited resources. DISCUSSION: This study provides insight into priorities for continued telehealth utilization focused on providing equitable access to perinatal care. Rather than returning to practices from before the COVID-19 pandemic formed from longstanding routines and perceived limitations, providers are encouraged to capitalize on the rapid innovations in telehealth to build a more effective, equitable, and patient-centered approach to perinatal care.

Sudden Shift to Telehealth in COVID-19: A Retrospective Cohort Study of Disparities in Use of Telehealth for Prenatal Care in a Large Midwifery Service.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic created disruption in health care delivery, including a sudden transition to telehealth use in mid-March 2020. The purpose of this study was to examine changes in the mode of prenatal care visits and predictors of telehealth use (provider-patient messaging, telephone visits, and video visits) during the COVID-19 pandemic among those receiving care in a large, academic nurse-midwifery service. METHODS: We conducted a retrospective cohort study of those enrolled for prenatal care in 2 nurse-midwifery clinics between 2019 and 2021 (n = 3172). Use outcomes included number and type of encounter: in-person and telehealth (primary outcome). Comparisons were made in frequency and types of encounters before and during COVID-19. A negative binomial regression was fit on the outcome of telehealth encounter count, with race/ethnicity, age, language, parity, hypertension, diabetes, and depression as predictors. RESULTS: When comparing pre-COVID-19 (before March 2020) with during COVID-19 (after March 2020), overall encounters increased from 15.9 to 19.5 mean number of encounters per person (P < .001). The increase was driven by telehealth encounters; there were no significant differences for in-person prenatal visit counts before and during the pandemic period. Direct patient-provider messaging was the most common type of telehealth encounter. Predictors of telehealth encounters included English as primary language and diagnoses of diabetes or depression. DISCUSSION: No differences in the frequency of in-person prenatal care visits suggests that telehealth encounters led to more contact with midwives and did not replace in-person encounters. Spanish-speaking patients were least likely to use telehealth-delivered prenatal care during the pandemic; a small, but significant, proportion of patients had no or few telehealth encounters, and a significant proportion had high use of telehealth. Integration of telehealth in future delivery of prenatal care should consider questions of equity, patient and provider satisfaction, access, redundancies, and provider workload.

Characterizing uterine responsiveness to oxytocin augmentation across four labor patterns in maternal obesity.

BACKGROUND: Optimizing care during labor protraction is a key strategy for reducing cesareans, especially among people with obesity. The pathophysiology of labor dystocia remains poorly understood, limiting precise interventions targeting the cause of protraction. METHODS: In this secondary analysis of nulliparas (n = 92) with obesity (BMI ≥ 30 kg/m2 ) and spontaneous labor onset, we classified labor into four phenotypes based on duration of protraction and birth route: (1) no protraction, (2) short protraction and vaginal birth, (3) extended protraction meeting criteria for labor arrest, but with eventual progression and vaginal birth, and (4) extended protraction meeting criteria for labor arrest and cesarean birth. Across these phenotypes, we compared MVU, oxytocin dose, and novel measures of uterine responsiveness to oxytocin augmentation (MVU to oxytocin dose ratios). RESULTS: In our sample, phenotype group 1 comprised 14.1% (n = 13); group 2 comprised 30.4% (n = 28); group 3 comprised 34.8% (n = 32); and group 4 comprised 20.7% (n = 19). Uterine responsiveness to oxytocin, but not MVU, decreased with each labor phenotype. Participants with cesarean birth had the lowest uterine responsiveness to oxytocin. CONCLUSION: Labor and birth outcomes were associated with measures of uterine responsiveness to oxytocin rather than MVU alone, and thus these may be more clinically appropriate measures for guiding clinical decision-making. Current criteria for labor arrest are likely too stringent for nulliparas with obesity, many of whom appear to progress to safe vaginal birth after longer labor durations. Differences in uterine responsiveness to oxytocin augmentation across the groups suggests underlying physiologic differences in the labor phenotypes, which should drive future research targeting pathophysiology.

The Relationship Between Uterine Activity, Oxytocin Dosing, Labor Progress, and Mode of Birth in Nulliparas with Obesity: Minimal Usefulness of Montevideo Unit Measurement.

BACKGROUND: Maternal obesity and cesarean birth disproportionately affect Black parturients; thus, prevention of cesarean birth is a key modifiable factor to improve pregnancy outcomes and reduce disparities. The primary driver of unplanned cesarean birth among people with higher body mass index is prolonged labor duration. However, strategies to optimize outcomes in these situations have not been established. We aimed to evaluate the influence of oxytocin augmentation on uterine activity and labor progression in nulliparas with obesity. METHODS: This secondary analysis involved nulliparas with obesity (BMI ≥30 kg/m2) who had spontaneous labor onset followed by oxytocin augmentation and an intrauterine pressure catheter. Using Linear Mixed Models, we evaluated relationships between uterine activity measured in Montevideo units (MVU), oxytocin dose, and rate of cervical dilation normalized by labor duration. RESULTS: In this diverse sample (35.6% Caucasian, 16.11% African American, 40.2% Hispanic) of nulliparas with obesity (n = 87; BMI 35.54 ± 4.38 kg/m2), 31% ended labor with cesarean birth. Among those with vaginal birth, only 13% had MVU ≥200 prior to the final 2 hours of labor. MVUs were only minimally responsive to oxytocin dose and were not associated with labor progression nor birth route. CONCLUSION: MVU measurements may not be useful to diagnose labor arrest in nulliparas with obesity. Optimizing care for birthing people with obesity is essential for improving perinatal outcomes and for reducing racial health disparities.

The Pathophysiology of Labor Dystocia: Theme with Variations.

Abnormally prolonged labor, or labor dystocia, is a common complication of parturition. It is the indication for about half of unplanned cesarean deliveries in low-risk nulliparous women. Reducing the rate of unplanned cesarean birth in the USA has been a public health priority over the last two decades with limited success. Labor dystocia is a complex disorder due to multiple causes with a common clinical outcome of slow cervical dilation and fetal descent. A better understanding of the pathophysiologic mechanisms of labor dystocia could lead to new clinical opportunities to increase the rate of normal vaginal delivery, reduce cesarean birth rates, and improve maternal and neonatal health. We conducted a literature review of the causes and pathophysiologic mechanisms of labor dystocia. We summarize known mechanisms supported by clinical and experimental data and newer hypotheses with less supporting evidence. We review recent data on uterine preparation for labor, uterine contractility, cervical preparation for labor, maternal obesity, cephalopelvic disproportion, fetal malposition, intrauterine infection, and maternal stress. We also describe current clinical approaches to preventing and managing labor dystocia. The variation in pathophysiologic causes of labor dystocia probably limits the utility of current general treatment options. However, treatments targeting specific underlying etiologies could be more effective. We found that the pathophysiologic basis of labor dystocia is under-researched, offering wide opportunities for translational investigation of individualized labor management, particularly regarding uterine metabolism and fetal position. More precise diagnostic tools and individualized therapies for labor dystocia might lead to better outcomes. We conclude that additional knowledge of parturition physiology coupled with rigorous clinical evaluation of novel biologically directed treatments could improve obstetric quality of care.

Concepts and metrics of clinician attention: a scoping review protocol.

INTRODUCTION: There is growing emphasis on the importance of both the cognitive and behavioural phenomenon of attention for clinicians engaged in patient care. Aspects of attention such as cognitive load, distraction and task switching have been studied in various settings with different methodologies. Using the protocol described here, we aim to systematically review the medical literature in order to map the concept of attention and to synthesise diverse concepts and methods under the broader category of research focused on 'attention'. METHODS AND ANALYSIS: Following the methodology described by the Joanna Briggs Institute and Arksey and O'Malley, our scoping review conducts an iterative search of Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline (PubMed) and EMBASE (Ovid). An initial limited search based on key concepts and terminology will generate relevant articles which in turn will be mined for additional keywords and index terms to guide a formal literature search. Our multidisciplinary team will extract data into a matrix, including a small random sample of the same studies (to ensure concordance), and present the results in a descriptive narrative format. ETHICS AND DISSEMINATION: As a secondary analysis, our study does not require ethics approval, and we will ensure that included studies have appropriate approval. We anticipate results will identify diverse ways of conceptualising clinician attention and will provide a foundation for developing additional metrics and study methods to optimise attention in the clinical environment. We will disseminate results through journals and conferences and coordinate with colleagues doing work in adjacent fields.

Innovations in Prospective Perinatal Research as a Result Of the COVID-19 Pandemic.

In 2020, in-person research activities were stopped because of the spread of the novel coronavirus, severe acute respiratory syndrome coronavirus 2, and the resulting disease, coronavirus disease 2019. Our collaborative team of nurse and midwife scientists at universities across the United States adapted research activities to continue prospective perinatal research during the pandemic. These adaptations included development of new research techniques and the implementation of previously developed, but underused, strategies to conduct research from a distance. These strategies included online recruitment, virtual enrollment and consent, qualitative data collection via video conferencing, new applications of smart phone technology, wearable biological measurement, and participant self-collection of biological samples. In addition to allowing research to continue during the pandemic, these innovative strategies may increase access to research for low-income, rural, and racially diverse pregnant and postpartum populations. Decreased travel requirements, flexible scheduling, wearable devices, and the capacity to self-collect biologic samples may improve recruitment and the experience of research participation. The rapid implementation of these research strategies has advanced innovation toward wider, more inclusive and increasingly diverse perinatal research access, and many of these strategies will continue to be used and refined.

Prenatal and Postpartum Experience, Knowledge and Engagement with Kegels: A Longitudinal, Prospective, Multisite Study.

Introduction: Urinary incontinence (UI) increases during pregnancy and continues into the postpartum period. Continued UI impacts women's comfort and affects aspects of their everyday lives. Kegel exercises have been found to decrease the incidence and severity of UI. The purpose of this study was to describe severity of UI, how women gained knowledge about Kegels, influences impacting Kegel exercises during pregnancy and postpartum, and characterize women's performance of Kegels. Methods: A longitudinal, prospective, multistate study was undertaken at four sites across the United States. Postpartum women completed the Pelvic Floor Control Questionnaire that incorporated the Sandvik Severity Index. At 3 and 6 months postpartum the women's UI, performance of Kegels, and affect on life was reviewed through seven questions. Institutional Review Board (IRB) approval was obtained. Results: Participants were 368 predominately multiparous, white women. Approximately 20% of women reported prepregnancy UI. Multiparous women reported similar incidence rate of UI regardless of birth history. Among one-fifth of the participants, persistent UI was reported as 45.2% at 3 months and 44.1% at 6 months postpartum. Only 25% of these women sought care. Women learned about Kegel exercises from written information or their provider. Women performed an average 16 Kegels twice daily. Kegel performance increased at 3 months postbirth but dropped by 6 months. UI was associated with age >35 and parity. Discussion: Prevalence of UI before and during pregnancy and postpartum is high, yet consistent Kegel performance postpartum is low. Screening for UI is necessary and high-quality referrals for treatment are needed. Consistent education is needed for all women. Education and support should be individualized. Future research is needed to identify techniques that motivate women to routinely perform Kegel exercises.

Women's Experiences of the Effect of Financial Strain on Parenting and Mental Health.

OBJECTIVE: To develop a conceptual theory to describe how financial strain affects women with young children to inform clinical care and research. DESIGN: Qualitative, grounded theory. SETTING: Participants were recruited from the waiting area of a pediatric clinic and an office of the Special Supplemental Nutrition Program for Women, Infants, and Children embedded within the largest safety-net academic medical center in New England. Participants were interviewed privately at the medical center or in the community. PARTICIPANTS: Twenty-six English-speaking women, mostly single and African American/Black, with at least one child 5 years old or younger, were sampled until thematic saturation was met. METHODS: We used grounded theory methodology to conduct in-depth, semistructured interviews with participants who indicated that they experienced financial strain. We analyzed the interview data using constant comparative analysis, revised the interview guide based on emerging themes, and developed a theoretical model. RESULTS: Five interrelated themes emerged and were developed into a theoretical model: Financial Strain Has Specific Characteristics and Common Triggers, Financial Strain Is Exacerbated by Inadequate Assistance and Results in Tradeoffs, Financial Strain Forces Parenting Modifications, Women Experience Self-Blame, and Women Experience Mental Health Effects. CONCLUSION: For women with young children, financial strain results in forced tradeoffs, compromised parenting practices, and self-blame, which contribute to significant mental health problems. These findings can inform woman-centered clinical practice and advocacy interventions. Women's health care providers should identify families experiencing financial strain, provide referrals to financial services, and join advocacy efforts to advance social policies that address the structural causes of poverty, such as increased minimum wage and paid family leave.

An Integrated Review of Uterine Activity Monitoring for Evaluating Labor Dystocia.

INTRODUCTION: Labor dystocia is the most common cause of cesarean birth in the United States, yet how dystocia develops during labor remains elusive. Uterine activity monitoring has significant potential for advancing our understanding of labor dystocia. While evaluating contraction frequency and amplitude is a common component of labor dystocia management, the literature describing the relationship between measures of uterine activity and labor dystocia is heterogeneous and has not been synthesized to identify the best methods for use in clinical investigation. METHODS: We conducted a literature search for original research exploring the relationship between uterine activity and labor dystocia published between 2000 and 2019. Included articles were critically reviewed and synthesized. RESULTS: Across 11 identified studies, investigators employed 3 different techniques for monitoring uterine activity and 9 different measures were employed. Uterine activity measures, including Montevideo units, uterine electromyography power density spectrum and sample entropy, and the fall-to-rise ratio of contraction shape, detected patterns associated with labor dystocia or cesarean birth. DISCUSSION: The use of multiple regression with clinical covariates and a uterine activity measure increased the accuracy of predicting cesarean delivery. Uterine electromyography may be especially useful to evaluate labor dystocia phenotypes to differentiate uterine muscle fatigue from understimulation and lead to algorithms for increased precision in the diagnosis of labor dystocia and innovative approaches to treatment.

A qualitative meta-synthesis of women's experiences of labor dystocia.

PROBLEM: Researchers have prioritized understanding and differentiating the pathophysiologic mechanisms to improve precision in diagnosis and individualization of care, however the experiences of women with labor dystocia have been underexamined. BACKGROUND: Management of labor dystocia has been identified as an opportunity for reducing the rate of unnecessary cesarean births and the associated risks to women and their infants. This meta-synthesis explores women's experiences of labor dystocia to enrich the discussion of care practices and contextualize discussions of shared decision making in what is most meaningful to women. QUESTIONS: How does prolonged labor influence women's experience of birth and motherhood? What are women's experiences with decision-making about labor augmentation during prolonged labor? METHODS: Sandelowski and Barroso's meta-synthesis approach was used to analyze primary qualitative studies of women's experiences of labor dystocia. Through inductive thematic synthesis and reciprocal translation, themes identified in qualitative research, quotations, and coded meaning units were aggregated and interpreted into derived categories and themes. FINDINGS: Fourteen qualitative studies were analyzed. Women experienced labor dystocia as a transition from healthy labor to abnormal labor requiring medical support consistent with Transition Theory by Meleis. Six new categories and thirty themes were identified. Each category and theme reflects a distinct component of the experience of labor dystocia. DISCUSSION/CONCLUSION: There is wide variation in the way women experience labor dystocia. Facilitation of the transition from healthy labor to labor dystocia can be supported by a fluid, adaptable method of caring for women in the face of uncertainty and loss of choice.

The experiences of midwives in integrated maternity care: A qualitative metasynthesis.

OBJECTIVES: To conduct a metasynthesis of eight qualitative studies of the experiences of midwives in integrated maternity practice; to identify common motifs among the eight studies through a thematic interpretive integration known as reciprocal translation; and to explore the effects on midwifery processes of care in the setting of integrated maternity practice. DESIGN: A qualitative metasynthesis to analyze, synthesize, and interpret eight qualitative studies on the experiences of midwives and the effect on the midwifery processes of care in the setting of integrated maternity practice. SAMPLE AND SETTING: Participants from the primary studies included a total of 160 midwives providing hospital-based intrapartum care. All primary studies were conducted in settings with midwives and obstetricians working together in an integrated or collaborative manner. FINDINGS: Three overarching themes emerged from the data: professional dissonance, functioning from a position of risk, and practicing down. KEY CONCLUSIONS: The findings indicated that integrated maternity practice affects the professional experience of midwives. Through a qualitative exploration, a clear process of deprofessionalization and deviation from the midwifery model of care is detailed. Midwives experienced decreasing opportunity to provide the quality woman-centered physiologic care that evidence shows benefits childbearing women. IMPLICATIONS FOR PRACTICE: Integrated maternity practice, where low-risk and high-risk pregnancies are managed by midwife/physician teams, have proliferated as a solution to the need for quality, safe, and efficient health care. Insufficient evidence exists detailing the success or failure of this model of care. Qualitative studies suggest that the increasing medicalization occurring in integrated maternity practices minimizes the profession of midwifery and the ability to provide evidence-based quality midwifery care.

Examining nurse/patient relationships in care coordination: A qualitative metasynthesis.

BACKGROUND: The combination of education, experience, skill mix, and frequency of nursing care provided has not been broadly studied from a systems theory perspective, in the care coordination process, or within transitions of care. PURPOSE: To examine nurse/patient relationships (as a proxy for nurse dose) in the care coordination experience through a qualitative metasynthesis using a systems theory approach. DESIGN: The study was a qualitative metasynthesis with four sequential processes; (1) a systematic literature search to answer the structured research question, (2) formal quality appraisal and data immersion, (3) interpretive synthesis of the data within and across studies, and (4) re-situating the derived themes through reciprocal translation to each of the primary studies. CINHAL, Cochrane Library, Embase and PubMed were searched, and 159 articles retrieved. Eight articles remained after inclusion/exclusion criteria and quality review criteria were applied. RESULTS: Key themes were organized using a systems theory perspective (Structure, Process and Outcomes). The need for a coordinated nurse-patient relationship and the ability of the nurse to calm the complexity that occurs forms the structure of the relationship. The process includes having an awareness of challenges of the coordinated nurse-patient relationship and the transitions that occur, nurses going above and beyond, providing meaningful communication, and navigating system complexity. The outcomes are the value of a coordinated nurse-patient relationship and managing the illness/wellness journey. CONCLUSIONS: The information from this metasynthesis provides an integrated view for nursing leaders and insight into factors that promote an effective and coordinated nurse-patient relationship.

Primary Prevention of Urinary Incontinence: A Case Study of Prenatal and Intrapartum Interventions.

A wealth of information is available regarding the diagnosis and treatment of urinary incontinence. However, there is a dearth of quality information and clinical practice guidelines regarding the primary prevention of urinary incontinence. Given the high prevalence of this concern and the often cited correlation between pregnancy, childbirth, and urinary incontinence, women's health care providers should be aware of risk factors and primary prevention strategies for stress urinary incontinence (SUI) in order to reduce associated physical and emotional suffering. This case report describes several common risk factors for SUI and missed opportunities for primary prevention of postpartum urinary incontinence. The most effective methods for preventing urinary incontinence include correct teaching of pelvic floor muscle training (PFMT; specifically Kegel exercises), moderate combined physical exercise regimens, counseling and support for weight loss, counseling against smoking, appropriate treatment for asthma and constipation, and appropriate labor management to prevent pelvic organ prolapse, urethral injury, and pelvic floor muscle damage.