A randomized trial of early hospital discharge and home follow-up of women having cesarean birth.

OBJECTIVE: To determine the safety, efficacy, and cost savings of early hospital discharge of women delivered by unplanned cesarean delivery. METHODS: Using randomized assignment, 61 postpartum women were discharged from the hospital at the usual time, and 61 were discharged early and had nurse specialist home follow-up care. The latter group received comprehensive discharge planning, instruction, counseling, home visits, and daily on-call availability from the nurse specialists. Both groups were followed from delivery to 8 weeks postpartum. RESULTS: Women who were discharged early and received transitional home care services by clinical nurse specialists were sent home a mean of 30.3 hours earlier than the control group (P < .001). They had significantly greater satisfaction with care, more of their infants had timely immunizations at the end of follow-up, and they had a 29% reduction in health care charges compared to the control group receiving routine care. Although there were no statistically significant differences in maternal and infant rehospitalizations and acute-care visits, there were more maternal rehospitalizations in the control group than in the nurse specialist-followed group (three versus zero). No statistically significant differences were found between the groups in the outcomes of maternal affect and overall functional status. CONCLUSION: Early hospital discharge of women after unplanned cesarean birth, using the model of nurse specialist transitional home care, is safe, feasible, and cost-effective.

A randomized trial of nurse specialist home care for women with high-risk pregnancies: outcomes and costs.

OBJECTIVE: To examine prenatal, maternal, and infant outcomes and costs through 1 year after delivery using a model of prenatal care for women at high risk of delivering low-birth-weight infants in which half of the prenatal care was provided in women's homes by nurse specialists with master's degrees. STUDY DESIGN: Randomized clinical trial. PATIENTS AND METHODS: A sample of 173 women (and 194 infants) with high-risk pregnancies (gestational or pregestational diabetes mellitus, chronic hypertension, preterm labor, or high risk of preterm labor) were randomly assigned to the intervention group (85 women and 94 infants) or the control group (88 women and 100 infants). Control women received usual prenatal care. Intervention women received half of their prenatal care in their homes, with teaching, counseling, telephone outreach, daily telephone availability, and a postpartum home visit by nurse specialists with physician backup. RESULTS: For the full sample, mean maternal age was 27 years; 85.5% of women were single mothers, 36.4% had less than a high school education, 93.6% were African American, and 93.6% had public health insurance, with no differences between groups on these variables. The intervention group had lower fetal/infant mortality vs the control group (2 vs 9), 11 fewer preterm infants, more twin pregnancies carried to term (77.7% vs 33.3%), fewer prenatal hospitalizations (41 vs 49), fewer infant rehospitalizations (18 vs 24), and a savings of more than 750 total hospital days and $2,496,145 [corrected]. CONCLUSION: This model of care provides a reasoned solution to improving pregnancy and infant outcomes while reducing healthcare costs.

Acute care visits and rehospitalization in women and infants after cesarean birth.

This study, conducted as a randomized clinical trial, focuses on acute care visits and rehospitalizations of mothers whose infants were delivered by cesarean section (n = 122) and infants (n = 123) for 8 weeks after hospital discharge. There were three maternal rehospitalizations. Maternal acute care visits were for wound infections or complications (27 of 34); 21 occurred in the first 4 weeks. Seventy-five percent of infant rehospitalizations were for infection or possible infection; 22 of 31 infant acute care visits occurred in first 4 weeks for bilirubin checks and infant care problems, and 21 of 25 visits in weeks 5 to 8 were for infections. Discharge teaching and home care in first 4 weeks after discharge and issues related to infant infections in the second 4-week period may reduce the need for rehospitalizations and acute care visits in both mothers who had cesarean section and their infants.

The high-risk infant environment. Part 2. The role of caregiving and the social environment.

Neonatal intensive care units are essential for the successful care of very immature and sick infants. The technology of NICUs has contributed significantly to the reduction of neonatal mortality and improvement of neonatal outcome. While the outcome for high-risk neonates has vastly improved over the past three decades, a number of infants sustain injuries and complications that result in long-term disabilities. It is now clear that some of the long-term problems of high-risk infants are a result of the environment and care practices and are not attributable to the original disease or condition that necessitated intensive care. There is accumulating evidence that environmental factors and care practices can interact with disease processes in ways that can increase morbidity, and possibly mortality. In addition to developmental and behavioral problems, there is growing evidence of effects on visual function and perhaps other sensory systems. Many of the environmental and care factors may cause delay in recovery and increase NICU time or unnecessary discomfort, yet not produce long-term disabilities or problems, as currently assessed. Many of the potential behavioral and developmental problems, as well as many of the potential problems with visual, auditory, and other modes of sensory discrimination, are not included in the usual follow-up assessments. The absence of data or the limitations of existing studies are not a cause for comfort or the assumption that the environment and care practices are safe or not harmful.(ABSTRACT TRUNCATED AT 250 WORDS)

Frequency, timing, and diagnoses of antenatal hospitalizations in women with high-risk pregnancies.

OBJECTIVE: To examine the frequency, time of gestation, and reasons for antenatal hospitalizations in women with medically high-risk pregnancies. STUDY DESIGN: This secondary analysis reports all antenatal hospitalizations from a clinical trial testing transitional care to women with high-risk pregnancies. Data were collected from 1992 to 1996. Pregnant women with pregestational (n = 16) or gestational diabetes (n = 21), hypertension (n = 29), and diagnosed (n = 47) or at high risk for preterm labor (n = 37) were included. Diagnoses for each hospitalization and lengths of stay were collected from chart review and validated by attending physicians. Gestation was determined via ultrasonography. The sample (N = 150) consisted of predominantly African-American women, never married, between the ages of 15 and 40 with Medicaid insurance. RESULTS: Eighty-three percent (n = 125) of the women had one or more antenatal hospitalization with a mean length of stay of 123 hours. All women with diabetes were hospitalized at least once. Women with pregestational diabetes had the greatest number of hospitalizations whereas those with gestational diabetes had the least. Major reasons for hospitalizations were preterm labor, glucose control, premature cervical dilation, and preeclampsia. CONCLUSION: Some hospitalizations could potentially be avoided or reduced through expanded patient education, improved screening, and more aggressive monitoring for early signs and symptoms of impending complications.

Maternal education during the perinatal period.

The nature of perinatal education has been transformed, reflecting the changes in health care and health care consumers. Because of short maternity stays, the venue of most perinatal education, especially postpartum education, has moved from hospitals to other areas, including the home. In light of conflicting findings of past research examining the effectiveness of prenatal education as well as gaps in the literature, there is a need for research on the content, methods, providers, and dose effect of perinatal education.

Utilization of inpatient services under shortened lengths of stay: a neonatal care example.

In the last several years many hospitals have experienced a significant reduction in average length of stay (LOS). We know relatively little about whether such reductions are likely to be accompanied by proportional reductions in the utilization of all inpatient services or whether services are merely condensed into a shorter time frame. Average patient severity may well rise as a result of shortened LOS, causing daily resource consumption to rise. In this paper, however, we hypothesize that patients with shorter LOS consume significantly fewer resources. Our empirical results support the hypothesis for some, but not all, of the services were examined.

Postdischarge services for low-birth-weight infants.

Efforts to improve infant mortality and morbidity should focus on preventing low birth weight and improving infant care. Although preventing low birth weight is the ultimate goal, nurses also must improve the care of infants who are born with low birth weights. This article examines postdischarge care for these infants and the nurse's role in providing follow-up services. Nurses have unique opportunities to influence infant well-being directly through continued contact with families and through interventions that support infant caregivers. However, continued research is needed to provide nurses with information about how follow-up for low-birth-weight infants can be best provided.

Breast-milk jaundice.

The syndrome of breast-milk jaundice, which often results in cessation of breastfeeding, maternal anxiety, and guilt, may be increasing. Research to date on pregnanediol, increased lipase, and free fatty acids as the causes of breast milk jaundice is reviewed. Variations in current treatment are presented and nursing measures supportive of parents and continued breastfeeding are provided.

Clinical specialist pre- and postdischarge teaching of parents of very low birth weight infants.

This study examined the pre- and postdischarge teaching needed by parents of very low birth weight infants (less than or equal to 1,500 g). The sample consisted of 36 families observed from the births of their infants to 18 months' postdischarge. Content analyses yielded five major teaching categories of infant, mother, family, home, and resources. Major predischarge teaching included feeding, recognition of infections, and growth and development. Major postdischarge teaching included feeding, current health problems, growth and development, and managing within the health-care system.

Early discharge and home care after unplanned cesarean birth: nursing care time.

OBJECTIVE: This study examined the mean nursing time spent providing discharge planning and home care to women who delivered by unplanned cesarean birth and examined differences in nursing time required by women with and without morbidity. DESIGN: A secondary analysis of nursing time from a randomized trial of transitional care (discharge planning and home follow-up) provided to women after cesarean delivery. SETTING: An urban tertiary-care hospital. PATIENTS: The sample (N = 61) of black and white women who had unplanned cesarean births and their full-term newborn was selected randomly. Forty-four percent of the women had experienced pregnancy complications. INTERVENTIONS: Advanced practice nurses provided discharge planning and 8-week home follow-up consisting of home visits, telephone outreach, and daily telephone availability. OUTCOME MEASURE: Nursing time required was dictated by patient need and provider judgment rather than by reimbursement plan. RESULTS: More than half of the women required more than two home visits; mean home visit time was 1 hour. For women who experienced morbidity mean discharge planning time was 20 minutes more and mean home visit time 40 minutes more. CONCLUSIONS: Current health care services that provide one or two 1-hour home visits to childbearing women at high risk may not be meeting the education and resource needs of this group.

Major concerns of women after cesarean delivery.

OBJECTIVE: To identify women's major physiologic, psychologic, and life-style concerns at 2 and 8 weeks after cesarean delivery. DESIGN: Descriptive study with open-ended interviews. SETTING: Large urban hospital affiliated with a major university. PARTICIPANTS: One hundred six women who had unplanned cesarean deliveries and delivered live, full-term neonates. The mean maternal age was 28.7 years. MAIN OUTCOME MEASURES: The major physiologic, psychologic, and life-style concerns. RESULTS: Seven women reported no concerns at both data points. The number of physiologic concerns that the women expressed decreased markedly from 2 to 8 weeks postdelivery, but the number of psychologic and life-style concerns did not. CONCLUSIONS: These findings reinforce the need for prenatal teaching and postnatal follow-up regarding these concerns.

Employment patterns and timing of birth in women with high-risk pregnancies.

OBJECTIVE: To describe the characteristics of employed women with high-risk pregnancies, their pattern of employment prenatally and postpartum, and the relationship of prenatal employment to preterm or full-term birth. DESIGN: Secondary analysis with a sample of 171 women with high-risk pregnancies. SETTING: Women's homes and a tertiary care hospital. PARTICIPANTS: Women who were primarily single, African American, and poor; 33% worked or attended school during their pregnancies. MAIN OUTCOME MEASURES: Gestational age at birth, employment, and school attendance. RESULTS: Preterm delivery was not related to when the women stopped working or attending school or were prescribed bed rest. Women employed prenatally were older, had higher incomes, and were more likely to be white or of ethnicity other than African American. Fifty-seven percent of women with a history of prenatal employment and 85% of the women who intended to work after delivery returned to work during the first postpartum year. CONCLUSIONS: Women employed during high-risk pregnancies are similar demographically to women with low-risk pregnancies in other studies. Most of the women stopped working or attending school because of prescribed bed rest. Bed rest, however, was not related to preterm delivery. Most women who planned to return to work did so. Factors other than the women's high-risk pregnancies, such as attitudes toward employment, employability, and family circumstances, most likely influenced their employment status. Current welfare reform initiatives will increase the number of women working while pregnant. This article provides pre-welfare-reform baseline data concerning patterns and effects of employment for women with high-risk pregnancies. These data will enable nurses to examine the effects of welfare reform on employment during pregnancy and preterm birth.

A computerized system for measuring the effect of nursing care activities on the clinical indices of energy expenditure.

A computerized system for measuring clinical indices of energy expenditure (heart rate, temperature and activity) was pilot tested on three low-birth-weight infants over a period of 24 hours. The mean heart rate was 163 beats/min and the following mean temperatures were recorded: heel, 34.7 degrees C; abdominal skin, 35.1 degrees C; incubator wall, 29 degrees C; and air, 25.5 degrees C. Activity, determined as the number of baseline crossings of the processed signal from a pressure mattress, was calculated to be 8-9 crossings/min. When compared with an established activity scale based on behavioral observation, a correlation of 0.84 was found. The system described is valid, reliable and interferes minimally with normal nursing activities.

Anxiety and depression in mothers of low birthweight and very low birthweight infants: birth through 5 months.

The purpose of this study was to compare two common psychologic stress responses, anxiety and depression, in 27 mothers of very low birthweight (VLBW; less than or equal to 1500 grams) preterm infants and 35 mothers of low birthweight (LBW; 1501-2500 grams) preterm infants from the time of the infant's birth until the infants reached 5 months adjusted gestational age. There were significant differences in the patterns of anxiety and depression experienced by mothers of LBW and VLBW infants over time. Mothers of VLBW infants had higher anxiety and depression until 2 months adjusted gestational age while mothers of LBW infants had higher anxiety and depression at 3 and 4 months. Nursing interventions designed to decrease stress during the first postpartal week and to counsel mothers about patterns of anxiety and depression they may experience over time may be useful.

Concerns of mothers of low birthweight infants.

To provide more comprehensive follow-up care for low birthweight infants, it is important for nurses to know what concerns mothers of these low birthweight infants commonly experience and how concerns change over time. This descriptive, longitudinal study followed 65 mothers of low birthweight infants from birth until the infant was 6 months adjusted gestational age. Most concerns were raised the week following birth (109) and after infant discharge (72), although from 40 weeks (62) to 6 months (40), the number of concerns raised were fairly consistent. The largest category of concerns was health related (253).

Effect of DRGs on research.

The author examines the present and potential impact of prospective payment systems and DRGs on research. DRGs are affecting the funding and direction of research. In addition, DRGs may already be affecting the statistical data bases used in research.

Measuring the effectiveness of nursing practice.

This article examines the importance of outcomes as indicators of quality of care. The appropriateness of selected traditional and emerging outcomes in measuring the effectiveness of nursing interventions is addressed.

Taxonomic classification of transitional follow-up care nursing interventions with low birthweight infants.

As new models of nursing care have merged, the need to understand the scope and content of nursing practice has increased. The domain of transitional follow-up nursing, an innovative model, was described by classification of nursing interventions according to the Taxonomy of Ambulatory Care Nursing. Content analysis of records of interventions employed by nurse specialists in the transitional follow-up care of very low birthweight infants yielded results that confirm the appropriateness of the Taxonomy of Ambulatory Care Nursing as a descriptor of transitional follow-up care.

The association between CNS direct care time and total time and very low birth weight infant outcomes.

This study examined the association between the amount of direct care time and total time (direct and administrative) spent by CNSs with families of 39 very low birth weight infants (< or = 1500 grams) and infant outcomes (rehospitalizations and acute care visits). Documentation of the CNSs' time spent with infants and families was recorded during infant hospitalization and for 18 months after infant discharge. The number of infant rehospitalizations and acute care visits was recorded from hospital and physician records. The mean total time the CNS spent per infant for the 18-month period was 27.3 hours. After discharge, there were significant relationships between the amount of CNS direct care time and the number of acute care visits (r = 0.45, p < 0.01) and infant rehospitalizations (r = 0.51, p < 0.01). Although the study findings did not demonstrate improved infant outcomes associated with the amount of time the CNS spent with this high risk population, they document the amount of CNS time spent in intervention and follow-up of these infants. This study provides data for costing home visiting by the CNS in this patient population.