A retrospective cohort study of hospital versus home care for pregnant women with preterm prelabor rupture of membranes.

OBJECTIVE: To compare maternal and neonatal outcomes between in-hospital management and prepartum care at home (PCAH) among women with preterm prelabor rupture of membranes (PPROM) before 34 weeks of pregnancy. METHODS: In a retrospective study, data were analyzed from women who experienced PPROM between 23 and 34 weeks of pregnancy, and received care from two hospitals in British Columbia, Canada, between April 2007 and March 2012. Women were included if they had been stable in hospital for at least 72 hours and met eligibility criteria for PCAH. Management of PPROM differs at the centers: at one, women are monitored in hospital, whereas PCAH is used at the other. Outcomes were compared between management strategies. Logistic regression was used to assess severe maternal morbidity and neonatal morbidity/mortality after adjustment for pregnancy length at PPROM. RESULTS: Among 176 included women, 87 received PCAH and 89 were managed in hospital. There was no difference in severe maternal morbidity (adjusted odds ratio [aOR] 0.64, 95% confidence interval [CI] 0.35-1.17) or neonatal morbidity/mortality (aOR 0.63, 95% CI 0.31-1.30). Latency increased and length of stay decreased with PCAH (P<0.001 for both). CONCLUSION: Maternal and newborn outcomes were similar between women who received PCAH and those who were managed in hospital. The reduced resource use in PCAH might lead to cost savings without compromising outcomes.

Perceptions of Canadian labour and delivery nurses about incident reporting: a qualitative descriptive focus group study.

BACKGROUND: Estimates of incidents (adverse events) occurring during inpatient hospital stays suggest patient safety demands attention. Improving the safety of health care systems requires understanding incidents and their causes. Labour and delivery nurses can contribute to understanding incidents and incident reporting because they actively identify and report incidents in practice. OBJECTIVES: To explore Canadian labour and delivery nurses' perceptions about reporting incidents in practice and identify factors facilitating or constraining incident reporting. DESIGN: A descriptive qualitative study design using focus groups to collect data. SETTINGS: Three labour and delivery units within one health authority in the province of British Columbia. PARTICIPANTS: Sixteen registered nurses participated in one of four focus groups between 2009 and 2010. METHODS: We audio-taped interviews, transcribed the data, and analysed interview data using inductive content analysis and constant comparison. RESULTS: We identified four main themes. The themes included determining an incident, the labour and delivery context, and barriers and facilitating factors for incident reporting. The nurses viewed incidents they identified as unique to their practice. Rather than being a single error, a series of events, which nurses often regarded as out of their control, could lead to incidents. The practice context for labour and delivery, specifically fear of litigation and complexity of decision-making about incidents, affected nurses' perceptions of incidents and incident reporting. Positive team dynamics complicated the process of incident identification and reporting. Nurses viewed lack of time and fatigue, inadequate reporting tools, and unit culture as barriers to incident reporting. Facilitating factors were learning opportunities, practice improvement, and professional responsibility. CONCLUSIONS: Team work in Canadian labour and delivery practice settings influences determinations of what constitutes incidents and how they are managed. The complexity of incidents that occur in perinatal practice contexts suggests new approaches would be valuable for incident reporting.

Development of a simplified protocol for administration of 20% magnesium sulphate for prophylaxis and treatment of eclampsia.

BACKGROUND: Magnesium sulphate is a high-risk medication that is used extensively for prophylaxis and treatment of eclampsia. To accommodate recommendations related to fluid restrictions and patient safety, a protocol was developed for the administration of 20% magnesium sulphate. OBJECTIVES: To determine whether administration of 20% magnesium sulphate increased the risk of phlebitis relative to 2% to 8% magnesium sulphate solutions, to determine if the institution's protocol for administration of 20% magnesium sulphate reduced errors during administration, and to identify strategies to further reduce potential errors. METHODS: A retrospective chart audit was undertaken for patients who had received magnesium sulphate for prophylaxis of eclampsia from December 2004 to December 2007. A failure mode and effect analysis was used to identify additional safety strategies. RESULTS: A total of 47 patients received magnesium sulphate according to the old administration protocol (2% to 8% solution) and 29 according to the new protocol (20% solution). No evidence of phlebitis was documented for any of these 76 patients. A few errors occurred with changes in rates or concentrations and because of failure to reset the pump after the loading dose, but there was no documented harm to any of the patients. Strategies to further reduce errors in the administration of magnesium sulphate included development of preprinted orders, use of 20% magnesium sulphate for all infusion rates, changes to pump settings to enable use of fractional infusion rates, preparation of magnesium sulphate in mini-bags in the pharmacy, double-check of pump settings by nurses, anesthesiology consult, and distribution of protocols to all areas in the hospital (to limit errors associated with patient transfers). CONCLUSIONS: There was no documented phlebitis, and fewer errors occurred when 20% magnesium sulphate was used. Several additional strategies were identified to reduce errors in the administration of this high-risk medication.

Deciding when it's labor: the experience of women who have received antepartum care at home for preterm labor.

OBJECTIVE: To describe how women who had received antepartum care at home for preterm labor managed subsequent episodes of preterm labor symptoms. DESIGN: Grounded theory method. SETTING: 2 Canadian antepartum home care programs. PARTICIPANTS: 12 women who received antepartum care at home for preterm labor that had been diagnosed in hospital prior to 34 weeks gestation. RESULTS: The core psychosocial process was reconciling body knowledge and professional knowledge. Study participants reported knowing something's not right and followed decision guides to seek help. If, when they returned to the hospital to see what's going on, they felt dissonance between what their bodies were telling them (body knowledge) and what their health care providers were telling them (professional knowledge) an overriding tension developed between not wanting to take a risk for the baby versus not wanting to overreact. These women reestablished their baselines of nonthreatening symptoms at a higher level by setting a new normal to avoid the humiliation associated with appearing to overreact. Attempting to ignore recurring symptoms of preterm labor delayed help seeking and caused anxiety. CONCLUSIONS: To avoid delayed help seeking, nursing interventions should be geared to reducing anxiety and validating the experiences of women with recurring preterm labor symptoms.