Operationalizing Whole-Person Postpartum Care: Health Care Provider-Level Strategies.

Postpartum mothers report feeling unsupported and unprepared by their health care providers to meet the challenges of the postpartum period. This gap perpetuates a cycle of disappointment with and disengagement from postpartum care services. The need to revamp postpartum care has been recognized at the population level but implementing changes at the health care provider level is challenging without practical guidance. The needs of new mothers are broad in scope and variable between individuals, requiring a whole-person care approach that is comprehensive yet nimble. Presented here are provider-level strategies to promote care that both elicits and is responsive to the unique care goals of this population.

Best Practices in Management of Postpartum Pain.

Pain has been documented as a major concern for women in the postpartum period. Management of postpartum pain, however, is a relatively neglected area of clinical research. As a result, evidence to support interventions to alleviate the discomforts associated with childbirth is sparse. This paucity of research on postpartum pain management is particularly surprising given that in the United States alone nearly 4 million women give birth each year. Inadequate pain relief in the hours to months following childbirth can interfere with maternal-newborn bonding and feeding and, by impeding mobility, can increase the risk of postpartum complications. In addition, pain that is not adequately managed may increase the risk of chronic pain that lasts beyond the postpartum period. In this article, the more common causes of pain following childbirth are reviewed and recommendations for pain management based on available evidence are outlined. Considerations for pain management in lactating women and for hospital discharge are discussed.

Impact Evaluation of PRONTO Mexico: A Simulation-Based Program in Obstetric and Neonatal Emergencies and Team Training.

INTRODUCTION: Most maternal deaths in Mexico occur within health facilities, often attributable to suboptimal care and lack of access to emergency services. Improving obstetric and neonatal emergency care can improve health outcomes. We evaluated the impact of PRONTO, a simulation-based low-cost obstetric and neonatal emergency and team training program on patient outcomes. METHODS: We conducted a pair-matched hospital-based trial in Mexico from 2010 to 2013 with 24 public hospitals. Obstetric and neonatal care providers participated in PRONTO trainings at intervention hospitals. Control hospitals received no intervention. Outcome measures included hospital-based neonatal mortality, maternal complications, and cesarean delivery. We fitted mixed-effects negative binomial regression models to estimate incidence rate ratios and 95% confidence intervals using a difference-in-differences approach, cumulatively, and at follow-up intervals measured at 4, 8, and 12 months. RESULTS: There was a significant estimated impact of PRONTO on the incidence of cesarean sections in intervention hospitals relative to controls adjusting for baseline differences during all 12 months cumulative of follow-up (21% decrease, P = 0.005) and in intervals measured at 4 (16% decrease, P = 0.02), 8 (20% decrease, P = 0.004), and 12 months' (20% decrease, P = 0.003) follow-up. We found no statistically significant impact of the intervention on the incidence of maternal complications. A significant impact of a 40% reduction in neonatal mortality adjusting for baseline differences was apparent at 8 months postintervention but not at 4 or 12 months. CONCLUSIONS: PRONTO reduced the incidence of cesarean delivery and may improve neonatal mortality, although the effect on the latter might not be sustainable. Further study is warranted to confirm whether obstetric and neonatal emergency simulation and team training can have lasting results on patient outcomes.

Team training in obstetric and neonatal emergencies using highly realistic simulation in Mexico: impact on process indicators.

BACKGROUND: Ineffective management of obstetric emergencies contributes significantly to maternal and neonatal morbidity and mortality in Mexico. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a highly-realistic, low-tech simulation-based obstetric and neonatal emergency training program. A pair-matched hospital-based controlled implementation trial was undertaken in three states in Mexico, with pre/post measurement of process indicators at intervention hospitals. This report assesses the impact of PRONTO simulation training on process indicators from the pre/post study design for process indicators. METHODS: Data was collected in twelve intervention facilities on process indicators, including pre/post changes in knowledge and self-efficacy of obstetric emergencies and neonatal resuscitation, achievement of strategic planning goals established during training and changes in teamwork scores. Authors performed a longitudinal fixed-effects linear regression model to estimate changes in knowledge and self-efficacy and logistic regression to assess goal achievement. RESULTS: A total of 450 professionals in interprofessional teams were trained. Significant increases in knowledge and self-efficacy were noted for both physicians and nurses (p <0.001- 0.009) in all domains. Teamwork scores improved and were maintained over a three month period. A mean of 58.8% strategic planning goals per team in each hospital were achieved. There was no association between high goal achievement and knowledge, self-efficacy, proportion of doctors or nurses in training, state, or teamwork score. CONCLUSIONS: These results suggest that PRONTO's highly realistic, locally appropriate simulation and team training in maternal and neonatal emergency care may be a promising avenue for optimizing emergency response and improving quality of facility-based obstetric and neonatal care in resource-limited settings. TRIAL REGISTRATION: NCT01477554.

The recognition and management of intrapartum fetal heart rate emergencies: beyond definitions and classification.

The ongoing and well-documented debate about the value of electronic fetal monitoring has focused primarily on the fact that most variant fetal heart rate (FHR) patterns are poor predictors of fetal acid-base status. Most recently, much of this attention has been focused on the implications for clinical management of FHR patterns that the National Institute of Child Health and Human Development has classified as indeterminate: neither normal nor abnormal. Given that a majority of fetuses will have an FHR pattern considered indeterminate at some point in labor, this is an important and worthwhile discussion. It is also important, however, for providers to be able to recognize those patterns that signal the presence of developing acidemia and those that signal the potential presence of an acute obstetric complication that can quickly lead to acidemia and fetal asphyxia, such as a placental abruption or uterine rupture. Early identification of these FHR patterns, and immediate intervention to improve oxygenation or expedite birth, may help improve neonatal outcomes. The first part of this article presents descriptions of theses FHR patterns. The route and timing of birth during these emergencies is then discussed. The last part of the article presents an overview of strategies for optimizing the efficiency of providers, particularly teams of providers, in responding to FHR emergencies. The use of simulation-based training is reviewed, with specific focus on its potential application in the context of preparing for these emergencies.

Understanding and meeting the needs of women in the postpartum period: the Perinatal Maternal Health Promotion Model.

A new model for the care of women in the postpartum focuses on the development of life skills that promote complete well-being. The year following childbirth is a time of significant transition for women. In addition to the physiologic changes associated with the postpartum period, a woman undergoes marked psychosocial changes as she transitions into a motherhood role, reestablishes relationships, and works to meet the physical and emotional needs of her infant and other family members. It is a time when women are vulnerable to health problems directly related to childbirth and to compromised self-care, which can manifest in the development or reestablishment of unhealthy behaviors such as smoking and a sedentary lifestyle. In addition to long-term implications for women, compromised maternal health in the postpartum period is associated with suboptimal health and developmental outcomes for infants. Maternal health experts have called for a change in how care is provided for women in the postpartum period. This article presents the rationale for a health promotion approach to meeting the needs of women in the postpartum period and introduces the Perinatal Maternal Health Promotion Model. This conceptual framework is built around a definition of maternal well-being that asserts that health goes beyond merely the absence of medical complications. In the model, the core elements of a healthy postpartum are identified and include not only physical recovery but also the ability to meet individual needs and successfully transition into motherhood. These goals can best be achieved by helping women develop or strengthen 4 key individual health-promoting skills: the ability to mobilize social support, self-efficacy, positive coping strategies, and realistic expectations. While the model focuses on the woman, the health promotion approach takes into account that maternal health in this critical period affects and is affected by her family, social network, and community. Clinical implications of the model are addressed, including specific health promotion strategies that clinicians can readily incorporate into antepartum and postpartum care.

Promoting cultural humility during labor and birth: putting theory into action during PRONTO obstetric and neonatal emergency training.

Maternal and neonatal mortality in Northern Guatemala, a region with a high percentage of indigenous people, is disproportionately high. Initiatives to improve quality of care at local health facilities equipped for births, and increasing the number of births attended at these facilities will help address this problem. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a low-tech, high-fidelity, simulation-based, provider-to-provider training in the management of obstetric and neonatal emergencies. This program has been successfully tested and implemented in Mexico. PRONTO will now be implemented in Guatemala as part of an initiative to decrease maternal and perinatal mortality. Guatemalan health authorities have requested that the training include training on cultural humility and humanized birth. This article describes the process of curricular adaptation to satisfy this request. The PRONTO team adapted the existing program through 4 steps: (a) analysis of the problem and context through a review of qualitative data and stakeholder interviews, (b) literature review and adoption of a theoretical framework regarding cultural humility and adult learning, (c) adaptation of the curriculum and design of new activities and simulations, and (d) implementation of adapted and expanded curriculum and further refinement in response to participant response.

PRONTO training for obstetric and neonatal emergencies in Mexico.

OBJECTIVE: To evaluate the acceptability, feasibility, rating, and potential impact of PRONTO, a low-tech and high-fidelity simulation-based training for obstetric and neonatal emergencies and teamwork using the PartoPants low-cost birth simulator. METHODS: A pilot project was conducted from September 21, 2009, to April 9, 2010, to train interprofessional teams from 5 community hospitals in the states of Mexico and Chiapas. Module I (teamwork, neonatal resuscitation, and obstetric hemorrhage) was followed 3 months later by module II (dystocia and pre-eclampsia/eclampsia) and an evaluation. Four elements were assessed: acceptability; feasibility and rating; institutional goal achievement; teamwork improvement; and knowledge and self-efficacy. RESULTS: The program was rated highly both by trainees and by non-trainees who completed a survey and interview. Hospital goals identified by participants in the module I strategic-planning sessions were achieved for 65% of goals in 3 months. Teamwork, knowledge, and self-efficacy scores improved. CONCLUSION: PRONTO brings simulation training to low-resource settings and can empower interprofessional teams to respond more effectively within their institutional limitations to emergencies involving women and newborns. Further study is warranted to evaluate the potential impact of the program on obstetric and neonatal outcome.

Clinical management of intra-amniotic infection and chorioamnionitis: a review of the literature.

Intra-amniotic infection (IAI), or chorioamnionitis, complicates up to 10% of all pregnancies and up to 2% of labors at term. There is a significant risk of complications for the mother and the neonate following IAI, including sepsis and pneumonia. In addition, there is a correlation between IAI and premature rupture of membranes, preterm premature rupture of membranes, preterm labor, and preterm birth. Research in the last decade has also revealed a complex and significant association between IAI and cerebral palsy and other central nervous system damage in both the preterm and term fetus. Timely diagnosis and treatment of IAI can significantly reduce the risk of both maternal and neonatal complications.

Shoulder dystocia: using simulation to train providers and teams.

Shoulder dystocia is an obstetric emergency that requires immediate recognition and a well-coordinated response. This response must include effective application of the maneuvers proven to relieve the impaction of the fetal shoulder and timely hand-off of the newborn to the neonatology team. The rare frequency of shoulder dystocia, coupled with patient safety concerns and the medico-legal environment, limits the opportunity of providers to learn and practice the management of shoulder dystocia. Training, especially simulation-based training, has been demonstrated to improve the management of shoulder dystocia. This article presents a review of the literature that supports simulation training for shoulder dystocia and provides guidance on creating and implementing shoulder dystocia training.

Ectopic pregnancy.

The incidence of ectopic pregnancy in the United States has been reported to be as high as 20 per 1000 pregnancies, a more than 4-fold increase over the last 20 years. Clinical presentation can range from subtle, nonspecific abdominal complaints to acute onset pain or hemorrhagic bleeding. This article reviews the associated risk factors, pathophysiology, diagnosis, and management of ectopic pregnancy. Clinicians must maintain a high index of suspicion whenever women who might be pregnant have abdominal complaints.