Applying Ethical Principles When Discussing Alcohol Use During Pregnancy.

Over the past 2 decades, more women in the United States are engaging in excessive alcohol use, including women of reproductive age. Consuming alcohol in amounts greater than recommended limits is associated with an increased risk for adverse health effects, such as breast cancer, hypertension stroke, spontaneous abortion, and infertility. No safe time, safe amount, or safe type of alcohol to consume during pregnancy has been identified. Contradictory beliefs about alcohol use, fear of stigmatization, and potential legal consequences can provide challenges for health care providers who communicate these risks to clients. Health care providers can help to prevent alcohol-related health issues, including alcohol-exposed pregnancies, by providing their clients with factual information about alcohol and health and client-centered options for reducing their health risks. Clinicians can use alcohol screening and brief intervention as a framework for applying the ethical principles of autonomy, veracity, beneficence, and nonmaleficence when talking with women in ways that are nonstigmatizing and supportive to help reduce their health risks and prevent alcohol-exposed pregnancies.

Obstetric and fetal triage.

Triage in healthcare is sorting patients by acuity to prioritize them for full evaluation. Standardizing this process with the use of triage acuity classification tools has been shown to improve patient flow and quality of care in the emergency department. The American College of Obstetricians and Gynecologists recommends that pregnant women be triaged based on acuity, rather than time of arrival, and that obstetric triage acuity scales can serve as templates for use at the facility level. Three obstetric triage acuity scales developed in North America are reviewed and the implementation of one in a system with 40 birth hospitals is described. Use of obstetric triage acuity scales resulted in timelier initial assessment and decreased wait times. Acuity, volume, and trends data helped improve nurse and provider staffing in triage units. These findings support the promise of obstetric triage acuity scales to promote efficient care.

Nurses Leading Safe Infant Sleep Initiatives in the Hospital Setting.

Every day, 10 otherwise healthy infants die from sleep-related deaths in the United States. These deaths, termed sudden unexpected infant death, remain the leading cause of post-neonatal death in the United States despite known modifiable risk factors and prevention recommendations. In birthing hospitals, many parents report being given incorrect and sometimes no information about infant sleep safety, which creates immediate and long-term safety concerns. In this article, we provide an overview of sudden unexpected infant death, including sudden unexpected postnatal collapse, and the latest safe sleep recommendations from the American Academy of Pediatrics. We also offer practical guidelines for nurses-those working at the bedside and those in leadership positions-who may be seeking to improve the quality of infant sleep practices in their organizations.

Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period.

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period.

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period.

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period.

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Consequences of Inadequate Staffing Include Missed Care, Potential Failure to Rescue, and Job Stress and Dissatisfaction.

OBJECTIVE: To evaluate responses of registered nurse members of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) to a survey that sought their recommendations for staffing guidelines and their perceptions of the consequences of inadequate nurse staffing. The goal was to use these member data to inform the work of the AWHONN nurse staffing research team. DESIGN: Secondary analysis of responses to the 2010 AWHONN nurse staffing survey. SETTING: Online. PARTICIPANTS: AWHONN members (N = 884). METHODS: Review of data from an online survey of AWHONN members through the use of thematic analysis for descriptions of the consequences of inadequate nurse staffing during the childbirth process. RESULTS: Three main themes emerged as consequences of inadequate staffing or being short-staffed: Missed Care, Potential for Failure to Rescue, and Job-Related Stress and Dissatisfaction. These themes are consistent with those previously identified in the literature related to inadequate nurse staffing. CONCLUSION: Based on the responses from participants in the 2010 AWHONN nurse staffing survey, consequences of inadequate staffing can be quite serious and may put patients at risk for preventable harm.

Providing Nursing Care Women and Babies Deserve.

Nursing Care Women and Babies Deserve describes the core habits of character, also called virtues, that nurses can strive to incorporate into their care of women and newborns. This commentary provides background on the development of Nursing Care Women and Babies Deserve, as well as inspiring examples of how nurses incorporate these virtues into their nursing practice.

Interrater Reliability Testing of the Maternal Fetal Triage Index.

OBJECTIVE: To conduct interrater reliability testing of the Maternal Fetal Triage Index (MFTI), a standardized tool for obstetric triage. DESIGN: Observational study of a convenience sample of nurses' triage assessments of hospital-based obstetric patients. SETTING: A birth unit of a suburban hospital located in a large metropolitan region with approximately 5,200 births annually. PARTICIPANTS: Ten registered nurses provided triage assessments of 211 pregnant women. METHODS: Using blinded paired triage assessments, we assessed the reproducibility of the triage priority levels assigned using the MFTI. RESULTS: Priority levels assigned by the MFTI research nurse and the study nurses were in agreement for 154 of the 211 (72.9%) triage assessments. The strength of agreement was classified as good based upon the weighted kappa score of 0.65. There was no statistically significant difference in the accuracy of assigning priority levels between the day and night shifts CONCLUSION: The interrater reliability of the MFTI met the minimum strength of agreement threshold goal of 0.60 when used by nurses in a large birth unit to assign priority for evaluation. Based on this finding, the MFTI can be recommended for use in obstetric triage settings. Additional testing should be done to measure how this standardized tool improves care processes and outcomes.

Content Validity Testing of the Maternal Fetal Triage Index.

OBJECTIVE: To describe the development and content validity testing of the Maternal Fetal Triage Index (MFTI), a standardized tool for obstetric triage. DESIGN: Online survey. PARTICIPANTS: Participants included 15 registered nurses, 15 certified nurse-midwives, and 15 physicians from across the United States who provided maternity care. METHODS: A convenience sample of experienced clinicians was used as content validators for the MFTI. An item content validity index (I-CVI) was computed for the tool's items and a scale content validity index (S-CVI) was computed for the tool's scale based on the responses submitted via the online survey. Two rounds of content validation occurred. RESULTS: In the first round of testing, a total of 12 of 61 items in the MFTI did not meet the I-CVI threshold of greater than 0.78 because of disagreement about clinical condition (75%) or priority level placement (25%). In the second round of testing, all but 3 of the 69 content items in the revised version of the MFTI had I-CVI thresholds greater than 0.78. These 3 items were related to vital sign values. The overall S-CVI score calculated for Round 2 only was 0.95, which was greater than the threshold of 0.90. CONCLUSION: The results of the content validity testing of multidisciplinary validators suggest that the MFTI is a valid tool for use in obstetric triage and evaluation settings.

Planning and evaluating evidence-based perinatal nurse staffing.

Nurse staffing decisions are high-cost decisions. Having too few nurses may cause more mistakes or more episodes of missed care resulting in worse outcomes, increased pain, and additional suffering and health care costs. Having too many nurses increases health care costs. The Organizing Frameworks for Calculating Nurse Staffing and for Evaluating Nurse Staffing Decisions presented in this article build on the American Nurses' Association's principle-based staffing models and Donabedian's framework for evaluating the quality of health care.

Transfer from planned home birth to hospital: improving interprofessional collaboration.

Women's heightened interest in choice of birthplace and increased rates of planned home birth in the United States have been well documented, yet there remains significant public and professional debate about the ethics of planned home birth in jurisdictions where care is not clearly integrated across birth settings. Simultaneously, the quality of interprofessional interactions is recognized as a predictor of health outcomes during obstetric events. When care is transferred across birth settings, confusion and conflict among providers with respect to roles and responsibilities can adversely affect both outcomes and the experience of care for women and newborns. This article reviews findings of recent North American studies that examine provider attitudes toward planned home birth, differing concepts of safety of birthplace as reported by women and providers, and sources of conflict among maternity care providers during transfer from home to hospital. Emerging evidence and clinical exemplars can inform the development of systems for seamless transfer of women and newborns from planned home births to hospital and improve experience and perceptions of safety among families and providers. Three successful models in the United States that have enhanced multidisciplinary cooperation and coordination of care across birth settings are described. Finally, best practice guidelines for roles, communication, and mutual accommodation among all participating providers when transfer occurs are introduced. Research, health professional education, and policy recommendations for incorporation of key components into existing health care systems in the United States are included.

General influenza infection control policies and practices during the 2009 H1N1 influenza pandemic: a survey of women's health, obstetric, and neonatal nurses.

BACKGROUND: An evaluation of infection control practices was conducted following the release of the Centers for Disease Control and Prevention (CDC) guidance regarding the care of pregnant women during the 2009 H1N1 influenza pandemic. This paper describes 9 general hospital practices. METHODS: A questionnaire was distributed electronically to 12,612 members of the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN). Respondents (N = 2,304) who reported working in obstetric or neonatal settings during the pandemic completed the questionnaire. RESULTS: Most (73%) respondents considered the Centers for Disease Control and Prevention's guidance very useful. Significantly more reported a written hospital policy for each practice during versus before the pandemic. Six of the 9 practices were implemented most of the time by at least 70% of respondents; the practices least often implemented were mandatory vaccination of health care personnel involved (52%) and not involved (34%) in direct patient care and offering vaccination to close contacts of newborns prior to discharge (22%). The most consistent factor associated with implementation was the presence of a written policy supporting the practice at the respondent's hospital. CONCLUSION: We offer a descriptive account of general hospital infection control policies and practices during the 2009 H1N1 pandemic. Factors associated with reported implementation may be useful to inform planning to protect women and children for future public health emergencies.

Influenza infection control practices in labor and delivery units during the 2009 H1N1 influenza pandemic.

OBJECTIVE: To assess the presence and usefulness of written policies and practices on infection control consistent with the Center for Disease Control and Prevention's (CDC) guidance in hospital labor and delivery (L&D) units during the 2009 H1N1 influenza pandemic. SETTING: Online survey. PARTICIPANTS: Of 11,845 eligible nurses, 2,641 (22%) participated. This analysis includes a subset of 1,866 nurses who worked exclusively in L&D units. METHODS: A cross-sectional descriptive evaluation was sent to 12,612 members from the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) who reported working in labor, delivery, postpartum, or newborn care settings during the 2009 H1N1 influenza pandemic. RESULTS: Respondents (73.8%) reported that CDC guidance was very useful for infection control in L&D settings during the pandemic. We assessed the presence of the following infection control written policies, consistent with CDC's guidance in hospital L&D units, during the 2009 H1N1 influenza pandemic and their rate of implementation most of the time: questioning women upon arrival about recent flu-like symptoms (89.4%, 89.9%), immediate initiation of antiviral medicines if flu suspected or confirmed (65.2%, 49%), isolating ill women from healthy women immediately (90.7%, 84.7%), ask ill women to wear masks during L&D (67%, 57.7%), immediately separating healthy newborns from ill mothers (50.9%, 42.4%), and bathing healthy infants when stable (58.4%, 56.9%). Reported written policies for five of the six practices increased during the pandemic. Five of six written policies remained above baseline after the pandemic. CONCLUSIONS: Respondents considered CDC guidance very useful. The presence of written policies is important for the implementation of infection control practices by L&D nurses.

Postpartum and neonatal nursing care during the 2009 H1N1 influenza pandemic.

We describe select influenza infection control policies and practices related to postpartum and newborn care during the 2009 H1N1 pandemic. In an online survey of obstetric and neonatal nurses, significantly more nurses indicated a written hospital policy supporting each of the practices during versus before the pandemic. The two practices least often implemented were temporary separation of healthy newborns from ill mothers (37.7 percent) and testing newborns for influenza virus infection if signs of influenza were observed (31.4 percent). Presence of written hospital policies increased implementation of practices. Findings may be useful to guide planning for future pandemics or other public health emergencies.

Update on Chlamydia and gonorrhea screening during pregnancy.

Pregnant women in the United States are underscreened for chlamydia and gonorrhea, despite recommendations for broad testing. This puts women and infants at risk of complications from untreated infections. Nurses and other clinicians who care for pregnant women have a responsibility to be up-to-date in their knowledge of screening guidelines and to provide appropriate counseling to pregnant women based on their individual risk factors.

Don't Rush Me . . . Go the Full 40: AWHONN's Public Health Campaign Promotes Spontaneous Labor and Normal Birth to Reduce Overuse of Inductions and Cesareans.

Don't Rush Me . . . Go the Full 40 is a grassroots public health campaign from the Association of Women's Health, Obstetric and Neonatal Nursing (AWHONN) that educates women about the physiologic benefits of full-term pregnancy for themselves and their babies. GoTheFull40.com seeks to increase the percentage of women who complete at least 40 weeks of pregnancy, decrease the percentage of women who choose elective induction or elective cesarean surgery, and increase nurses' and other pregnancy-care providers' effectiveness in reducing the number of elective inductions and cesarean surgeries. Childbirth educators and other pregnancy providers are asked to share the campaign with women in preconception and prenatal settings to encourage waiting for spontaneous labor leading to full-term births when all is healthy and well with the mother and fetus.

Contraception is health promotion.

Contraception can be considered a means of health promotion because when women control the timing of their childbearing, they, together with their health care providers, can ensure that they are healthy before conception, thereby minimizing risk of complications of pregnancy and childbirth. Ensuring that women have accessible and affordable contraceptive services takes on a new urgency in the current context of rising rates of maternal morbidity and mortality in the United States.