Severe maternal and perinatal outcomes from uterine rupture among women at term with a trial of labor.

OBJECTIVE: To describe maternal and perinatal morbidity and mortality associated with uterine rupture (UR) among women with prior cesarean/s, singleton term pregnancies and a trial of labor after cesarean (TOLAC). STUDY DESIGN: Linked hospital discharge files and birth/fetal death certificates identified potential cases of UR in Massachusetts from 1990 to 1998 with definitive identification by medical record abstraction. RESULT: Among the 347 identified URs, severe outcomes occurred in 86 cases (25%), in 49 (14%) of mothers and 49 (14%) of infants. Of the infants, 25 were discharged with a good prognosis. Maternal age and interdelivery interval <18 months (relative risk (RR)=1.55; 95% confidence interval (CI): 1.05, 2.31) were associated with a severe outcome. The type of hospital and labor were not associated with the increased risk of a severe outcome. CONCLUSION: Assuming a 0.7% UR rate among women at term with a TOLAC, the increased rate of severe outcomes related to UR above the baseline risk of elective cesarean is estimated to be 1.3 per 1000 TOLACs.

A "conservative" approach to iron supplementation during pregnancy.

A review of current knowledge about iron metabolism during pregnancy and the evidence from various studies on the effects of iron supplementation in pregnancy on maternal, fetal, and infant outcomes suggest that the implicit goal of current recommendations regarding iron supplementation may be to achieve the highest hemoglobin concentration possible. This goal is only weakly related to improved maternal and infant outcomes in the current pregnancy or to improved maternal iron stores long-term. Indeed, the claim that iron supplementation is universally innocuous is shown to be controversial. For women in developed countries who are generally clinically healthy and have access to adequate nutrition, the benefits of iron supplementation are unclear, and there may be risks. Thus, a better "conservative" approach may be that such women do not require routine iron supplementation during pregnancy. The midwifery philosophy of individualizing care based on a woman's history and health status is one that should be taken in approaching the issue of iron supplementation in pregnancy.

A comparison of two time intervals for the ausculated acceleration test.

OBJECTIVE: Interest in an inexpensive, easy-to-administer antenatal screening test that did not rely on the use of electronic fetal monitoring led to development of the fetoscope administered auscultated acceleration test (AAT) in the late 1980s. More recent efforts have been directed toward providing those who may use the AAT with important information about the most effective and clinically appropriate AAT procedures. The purpose of this study was to determine the screening test validity performance of two AAT time intervals--6 minutes and 10 minutes. METHODS: Two auscultated acceleration tests (AAT6 and AAT10) were simultaneously performed using different time intervals on 205 women with high-risk pregnancies undergoing simultaneous nonstress tests (NSTS) who were referred to a tertiary care unit for antepartum testing. Standard measurements of screening test validity were calculated for each test in the prediction of selected perinatal outcomes. NST findings were included for comparative purposes. RESULTS: The AAT6 yielded an overall higher specificity as compared with the AAT10 at the expense of a slightly lower sensitivity for most perinatal outcomes; these differences were not significant at the .05 level. Relative risk ratios were similar for the AAT6 and AAT10 for both fetal distress and neonatal morbidity, with both AAT being a more effective predictor of neonatal morbidity than for fetal distress. Both tests yielded better sensitivity when compared with NST. CONCLUSIONS: Even though there was a nonsignificant trend toward higher sensitivities and lower specificities for the 10-minute AAT, this study showed that the differences in prediction of perinatal outcomes between the 6-minute and 10-minute AAT were minimal. In view of the added labor required for the 10-minute AAT in the absence of enhanced screening test validity, the 6-minute AAT is clinically preferred. This study has prompted new research questions for the continued development of the AAT as a low-technology fetal assessment technique with potential usefulness by midwives and their colleagues in a variety of settings worldwide.

Population-based primary health care for women. An overview for midwives.

This home study program has as its focus population-based care for women. Although clearly significant, concentrating effort solely on the individual does not ensure that the population as a whole is healthier. Experts are encouraging health care providers to consider the population as their "patient" and to begin documenting the incidence and prevalence of its disease. This article addresses the following issues: the definition of population-based health care; the relationship between primary care, women's health care, and population-based health care; the importance of a population-based approach or perspective for midwives; the use of population-based care in the provision of prenatal care; the definition of the populations to whom midwives have historically provided care and the documentation of how those populations are changing; and the research and policy issues for midwives related to population-based health care.

Primary care for women. Management of common problems of the head and neck.

As the companion article to Part I of the Journal of Nurse-Midwifery (JNM) series on "Primary Care for Women: Comprehensive Assessment of the Head and Neck", the pertinent primary care management steps involved in the prevention and treatment of problems of the head and neck in women are addressed. Emphasis is placed on the diagnosis and management of the most common head and neck illnesses; less common diagnoses that may be acute, seasonal, and/or life-threatening are also presented. Collaborative roles in the management of women with problems of the head and neck are discussed, and emphasis is placed on the importance of both preventive strategies and coordination of referrals.

Primary care for women. Cultural competence in primary care services.

The assessment of cultural competence in providing primary care services for women is addressed. Emphasis is placed on the ways in which cultural competency attainment can ensure the availability of key primary care components to all women, especially those from certain vulnerable populations and those who have specific primary health care needs. A cultural competence continuum is described that will assist providers in an assessment of their own cultural competency levels, as well as those of the service settings in which they practice. Six scenarios are provided, describing experience at each level of the continuum that may hinder the development and delivery of effective primary care service interventions. Examples of ways in which nurse-midwives can provide leadership in the area of cultural competence in women's primary care are also included.

Primary care for women. An overview of the role of the nurse-midwife.

The nurse-midwife's past, present, and future roles in the primary care of women are explored using a recent Institute of Medicine report on primary care as a framework for discussion. Primary care, the scope of services, and the role of the primary care clinician are described, and specific strategies for a primary care emphasis in basic nurse-midwifery education are addressed. The nurse-midwife's future roles in collaborative practice for the primary care of women and the need for continuing education opportunities in primary care are also discussed.

Twelve years and more than 30,000 nurse-midwife-attended births: the Los Angeles County + University of Southern California women's hospital birth center experience.

This article describes the setting, policies, practices, and outcomes of the nurse-managed in-hospital birth center at Los Angeles County + University of Southern California Women's Hospital, where women are selected upon admission for birth center care. A retrospective review of available data was made; when compared with hospital records, the primary data source was found to be 96% accurate. Results of the review indicated that from 1981 to 1992, there were 36,410 birth center admissions and 30,311 births, all attended by nurse-midwives; no intrapartum maternal or fetal deaths occurred among all admissions. The intrapartum transfer rate averaged 17%, and declined steadily from a high of 28% in 1982 to a low of 7% in 1990. More in-depth review showed an overall primary cesarean birthrate of 1.8% and an operative birthrate of 4% among the 25,890 admissions and 22,490 births from 1985 to 1992. Detailed postpartum and newborn outcomes from 1982 to 1986 showed a neonatal intensive care unit admission rate of 1.5% and a one-week newborn readmission rate of 1.3% among newborns discharged within 12 to 24 hours; 85% of all newborns returned for follow-up care. This large longitudinal experience demonstrates excellent outcomes that can be achieved when nurse-midwives, working cooperatively with a multidisciplinary health care team, provide in-hospital birth center care to a predominately low-income Hispanic population using a variety of less-traditional intrapartum management techniques. Broader implications for making alternative maternity care services available for low-income women with nurse-midwives and nurses playing a central role are discussed.

Perineal care. Then and now.

Since the late nineteenth century, the average postpartum woman has been subjected to a great deal of swabbing, soaking, and spraying, all in the name of perineal care. Many elaborate regimens have been devised to prevent infection, promote healing, and provide comfort to the mother, often based on little physiologic rationale or research data. All of these regimens have taken away valuable time and energy that the new mother needs for more important tasks. A review of past and current perineal care practices and major research studies relative to perineal care can form a foundation from which to evaluate and update the management of perineal care.

Papanicolaou smear: an update on classification and management.

Current research has caused us to reconsider the factors associated with cervical dysplasia. New recommendations for the collection of cervical specimens, interpretation of the Papanicolaou smear, and patient management have also evolved. Research findings and a discussion of the classifications to be used when reporting the results of the smear are updated in this paper. Interpretation and nurse-practitioner management of the normal and mildly abnormal Pap result is included.