Trauma-Informed Psychosocial Screening and Care Planning: A Patient-Centered Improvement Project in a Midwife Clinic.

INTRODUCTION: Traumatic stress is associated with increases in preterm birth, low birth weight, and other perinatal complications. Yet the identification of patients with traumatic stress and intervention for traumatic stress prevention or treatment remain low. Locally in this university hospital-based midwife clinic, a health records review found that trauma exposure was documented in 5% of patient records, and no records had a diagnosis of posttraumatic stress disorder (PTSD). This is lower than research-based population estimates of 25% to 50% for trauma exposure and 8% for PTSD during pregnancy. The clinic staff did not screen for posttraumatic stress, and exposure screening was limited to intimate personal violence. Staff had not been trained in trauma-informed care (TIC) as defined by the Substance Abuse and Mental Health Services Administration. The aim for this improvement project was to provide trauma screening and trauma-related care planning, collectively referred to as trauma-informed psychosocial care, to midwifery patients 85% of the time. PROCESS: Interventions were implemented over 4 plan-do-study-act (PDSA) cycles. These included staff training in TIC; written screening at the new prenatal, third trimester, and postpartum visits; verbal broad inquiry at every visit; and bidirectional trauma-specific care planning emphasizing patient and provider input into treatment choice. The clinic flow was changed to create privacy for patient-staff interaction at every visit. Field notes and data were analyzed every 2 weeks and iterative changes applied. OUTCOMES: Trauma disclosure increased from 5% to 30% and identification of PTSD from 0% to 7%. Bidirectional care plan documentation increased from 8% to 67%. Staff rated the workload as reasonable. DISCUSSION: Redesigning psychosocial screening to align with TIC principles increased the discovery of trauma to levels consistent with research-based population estimates. Gains were made in bidirectional care planning. This project illustrates practical methods of implementing TIC principles.

Timing and Outcomes of an Indication-Only Use of Intravenous Cannulation During Spontaneous Labor.

INTRODUCTION: In the United States, most women presenting in spontaneous labor undergo intravenous (IV) cannulation on admission to hospital labor and birth units. There is limited evidence for this routine practice in pregnant women at low risk for adverse outcomes during labor or birth. METHODS: A retrospective, exploratory, descriptive study of an indication-only practice of IV cannulation on admission for women presenting in spontaneous labor and cared for by a nurse-midwife service was performed. Descriptive data included the timing of IV cannula placement (admission, during labor or postpartum period, or not at all) and indications for placement. Maternal outcomes of interest were estimated blood loss, postpartum hemorrhage rates, and management; neonatal outcome was 5-minute Apgar scores. RESULTS: Records for 1069 women cared for by nurse-midwives who presented in spontaneous labor were reviewed. In this cohort, 445 (41.6%) had IV access established on admission, 325 (30.4%) had an IV cannula placed during labor or postpartum, and 299 (28%) never had IV access during their hospital stay. For the 325 women with IV cannulas placed after admission, 25 (7.7%) were placed urgently for excessive postpartum bleeding. Further analysis of the subset of women who had a postpartum hemorrhage after vaginal birth (defined as >500 mL estimated blood loss) indicated that urgent IV cannulation was not associated with a lower mean postpartum hemoglobin or hematocrit or an increase in blood transfusion rate when compared with women who had an IV cannula placed earlier in their labor course. DISCUSSION: Indication-only IV cannulation for women experiencing an uncomplicated labor and birth is a reasonable practice in settings where IV access can be established urgently if needed.

Neonatal care in the home in northern rural Honduras: a qualitative study of the role of traditional birth attendants.

Traditional birth attendants (TBAs) have limited ability to reduce maternal mortality, but may be able to have a significant impact on neonatal survival. This qualitative study explores TBAs' (possessive) experience with neonatal care in a rural Honduran community. In 6 semistructured focus groups, TBAs described services they routinely provide to newborns. Using Atlas.ti, Version 6.0. (ATLAS.ti Scientific Software Development GmbH, University of Berlin), transcripts were coded by bilingual researchers and analyzed by thematic content. TBAs demonstrated limited knowledge of newborn physiology, yet were aware of many internationally recommended practices. Despite attempts to follow recommendations, all TBAs expressed difficulty due to resource constraints. TBAs were strong advocates of immediate breast-feeding and skin-to-skin care, but they did not demonstrate knowledge regarding delayed bathing and thermal care. Most TBAs stated that a sick neonate could be identified immediately at birth; thus, infections or other illnesses developed in later days may be missed. TBAs did not believe they could have averted neonatal complications or deaths that had occurred under their care. For most healthy newborns, TBAs are the primary providers until the 2-month vaccine visit at the healthcare clinic. Improved TBA training focused on infection symptomotology, physiology, and thermoregulation for newborns may increase opportunities for improved health and timely referrals to healthcare facilities.

Reduced postpartum hemorrhage after implementation of active management of the third stage of labor in rural Honduras.

OBJECTIVE: To assess outcomes after auxiliary nurses were trained and given resources to use active management of the third stage of labor (AMTSL) for all women giving birth in a low-resource, low-risk, rural, public birth center setting in northern rural Honduras. METHODS: Auxiliary nurses received training on estimation of blood loss before the preintervention phase of the study (July 2004 through April 2005) and AMTSL, including use of intramuscular oxytocin, and estimation of blood loss prior to the intervention phase (July 2007 through June 2008). Preintervention and intervention data on use of oxytocin, blood loss postpartum, hemorrhage rates, and management interventions were collected and compared. RESULTS: After nurses received training on AMTSL using intramuscular oxytocin, the use of intramuscular oxytocin during the third stage of labor increased from 63.8% to 96.5%. Postpartum hemorrhage rates decreased from 14.8% to 5.9% (P=0.001). Use of intrapartum oxytocin, which can have adverse effects, also increased: from 6.1% to 22.7% (P<0.001). CONCLUSION: Training auxiliary nurses to perform AMTSL using oxytocin in this birth center setting was effective in reducing the rate of postpartum hemorrhage; however, increased use of intrapartum oxytocin may be an unintended outcome of the increased accessibility of oxytocin.

Childbirth education and birth plans.

Childbirth education is considered a key component to prenatal care, although many women do not receive any formalized preparation. There are multiple models of childbirth education for both within health care settings, including Centering Pregnancy, and external programs, such as Lamaze and Bradley. As a component of childbirth preparation, a birth plan can be a medium to improve patient-provider communication regarding a desired labor and birth experience and improve satisfaction with care.

Postpartum hemorrhage prevention: a case study in northern rural Honduras.

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality globally. Safe Motherhood policies have been directed towards the reduction of PPH by recommending active management of third-stage labor as the standard of care. One component of active management involves routine use of a uterotonic agent within 1 minute of the delivery of the baby. A case study at Clínica Materno-Infantil, a free-standing public birth center in Honduras, is presented, focusing on methods to reduce PPH. The nursing staff was trained to estimate blood loss and in methods to manage PPH, including elements of active management of the third stage of labor. Medical records were reviewed and an analysis of PPH management compared to estimated blood loss (EBL) was conducted. There was no significant correlation between PPH management techniques and EBL (r = .060; P = .368). There was a statistically significant (P < .001) correlation between oxytocin administration and lower EBL (r = -.232), indicating that there was less blood loss when oxytocin was administered. At Clínica Materno-Infantil, routine use of a uterotonic agent appears beneficial and further implementation of active management of the third stage of labor appears warranted.

Challenges for traditional birth attendants in northern rural Honduras.

OBJECTIVE: to explore the relationship between community-based parteras, the staff at the Centro Materno Infantil (Mother-Child Centre), and other public health facilities within the district of Morazán in northern rural Honduras during the transition to new models of maternity care. DESIGN: focus-group discussions with two groups composed of a convenience sample of community parteras. After verbatim translation of the interviews, the transcripts were analysed for content. SETTING: the Centro de Salud of Morazán, Yoro Honduras. PARTICIPANTS: 28 community-based parteras and one partero (male community midwife). FINDINGS: five themes emerged from the focus group data: the shared view that attending birth is connected to a religious calling; the desire for additional training; the desire for support from, and connection to, existing public-health services and infrastructure; the role of parteras in providing services to women who otherwise would not receive care; and the lack of new parteras to carry on this work in the future. KEY CONCLUSIONS: traditional birth attendants are still relied upon to serve more than half of the childbearing women in Honduras. The findings from the focus groups provide a foundation upon which to strengthen the relationship between community-based parteras and the government-funded systems of health care during this time of transition to new models of maternity care.

Adults' knowledge and behaviors related to human papillomavirus infection.

BACKGROUND: Our objective was to assess adults' knowledge, risk behaviors, and preference for information about human papillomavirus (HPV). METHODS: A cross-sectional study using a self-administered questionnaire given in 3 locations (a university health service and 2 community family practice offices); 289 people completed the questionnaire. The primary outcome measure was a knowledge score calculated from the responses on specific items in the questionnaire. This knowledge score was developed by other investigators and has acceptable psychometric properties. RESULTS: Knowledge about HPV was low, with an average knowledge score of 5.50 (possible scores ranged from 0 to 14) and a mode of 0. Knowledge scores were significantly higher in women (P =.001) and married adults (P =.001). Knowledge scores were inversely related to age (P =.004) and positively correlated with years of education (P =.001) and self-assessment of knowledge (P <.001). Knowledge scores were positively correlated with condom use (P =.05) but not significantly associated with other risk behaviors. The most frequently desired time to receive information about HPV was before becoming sexually active. CONCLUSIONS: Adults seen in a typical family physician's office have limited knowledge of HPV. One tool family physicians can use to identify those with the least amount of knowledge is to ask patients how informed they are about HPV. The preferred time to receive information about HPV was before a patient became sexually active. However, it remains unclear whether educational intervention or knowledge changes risky behaviors.

Recruitment and retention of economically underserved women to a cervical cancer prevention trial.

This review contrasts the planned and actual recruitment and retention efforts for a cervical cancer prevention study within a predominantly underserved population. Recruitment was a primary obstacle to trial progression and multiple strategies to improve recruitment were implemented to meet objectives. The actual recruitment strategies were expansion to five geographically distinct clinical sites, use of nurse practitioners focused primarily on patient issues, extremely flexible study hours and location, honorariums, support for transportation and child care, and creativity in maintaining contact with study participants. With these strategies, 90% of eligible patients consented to participate in the study.