Interpretation of biophysical profiles by nurses and physicians.

OBJECTIVE: To determine the agreement between nurse and physician interpretation of biophysical profile scores. DESIGN: A prospective evaluation of videotaped biophysical profiles was independently scored by four nurse and four physician interpreters and compared to that of an expert physician. SETTING: The fetal assessment center of a large tertiary-care center; study included women from public and private practices. PATIENTS: Twenty-three women with high-risk pregnancies who were regularly scheduled for a biophysical profile. Women pregnant with multiple fetuses or whose fetuses were less than 28 weeks' gestational age or had severe fetal anomalies were excluded. MAIN OUTCOME MEASURE: The proportion of agreement between the physicians and nurses and the physician expert was calculated for each biophysical profile criterion. RESULTS: The kappa statistic was used to evaluate the proportion of agreement with the "gold standard." When compared with the expert, physicians showed 60% moderate or substantial agreement, and the nurses showed 80% moderate or substantial agreement. CONCLUSIONS: Nurses' interpretations of biophysical profiles were at least as reliable as physicians' when compared with an expert reviewer.

Third-trimester ultrasound for nurse-midwives.

Obstetric ultrasound has become well integrated into management of pregnancy, labor, and delivery. An increasing number of nurse-midwives have expanded their roles to include the use of this technology. This article reviews the basic principles of ultrasound physics, the content of ultrasound examinations, and the performance of basic scans. The uses of limited scans for third-trimester antepartum assessment and intrapartum management are reviewed. Issues surrounding the use of obstetric ultrasound, including limited scans, routine ultrasound screening, and necessary education, are discussed. Information on incorporating the use of ultrasound procedures into nurse-midwifery practice is included.

Midwifery care for women with human immunodeficiency virus disease in pregnancy. A demonstration project at the Johns Hopkins Hospital.

Nurse-midwives at the Johns Hopkins Hospital, in conjunction with their colleagues in obstetrics, pediatrics, and infectious disease, are participating in a demonstration project designed to provide continuity of care for women with HIV disease in pregnancy. In the past 19 months, 73 women have been enrolled in the project. This article describes how the midwifery model of care has been integrated into the existing system of routine obstetric care and specialized HIV-related care at the institution. This project could serve as a model for others who are redesigning health care delivery systems to include more nurse-midwives, especially those who are trying to adapt to an ever-increasing number of women experiencing some phase of HIV disease during their pregnancy. A companion article explains the midwifery and medical protocols used in the project and discusses other clinically relevant issues.

Nurse-midwifery management of women with human immunodeficiency virus disease.

Primary care for women with human immunodeficiency virus (HIV) disease is appropriately provided by nurse-midwives within a well-coordinated system of medical consultation and referral. The issues of access to care, partner notification, reproductive choice, and breast-feeding are discussed. The nature of the collaborative management of HIV in pregnancy is explained. Management issues include the effects of HIV infection and pregnancy upon each other, perinatal transmission risks and postpartum needs, family planning, and gynecologic needs. Clinical care guidelines are included.

Effect of fetal movement on the amniotic fluid index.

OBJECTIVES: Fetal movement has been shown to change the size and location of amniotic fluid pockets during measurement of the amniotic fluid index. The effect of redistributing the fixed intrauterine fluid volume on the amniotic fluid index is unknown. Therefore we tested the hypothesis that the amniotic fluid index was unaffected by fetal movement. STUDY DESIGN: A single examiner prospectively determined the amniotic fluid index before and after three discrete episodes of fetal movement during 96 biophysical profiles. A reliable blinded examiner provided a second postmovement measurement as a control. Data were analyzed by the paired t test. RESULTS: The mean change in the amniotic fluid index after fetal movement was 1.5 +/- 0.1 cm and 2.5 +/- 0.2 cm for postmovement determinations by the same examiner and blinded observer, respectively (p < 0.001). CONCLUSION: Interobserver and intraobserver variation can account for the change in the amniotic fluid index after fetal movement.

Obstetric ultrasound: who should perform sonograms?

Obstetric ultrasound has revolutionized clinical practice by expanding knowledge of fetal growth, physiology, and behavior, and allowing the fetus to emerge as a treatable patient. This dramatic change in clinical practice has not been accompanied by a growth in education or guidelines for the performance of ultrasound studies. This article reviews some of the many professional issues that are still unresolved, such as education, level of care providers, office versus hospital scanning sites, level of ultrasound study, legal issues, obstetrics versus radiology as appropriate specialties to perform sonograms, and implications affecting childbearing women, based on concern for quality care of mothers and babies.

A comparison of the auscultated acceleration test and the nonstress test as predictors of perinatal outcomes.

In this prospective study, the predictive ability of the nonstress test (NST), the most widely used antepartum screening test to assess fetal well-being, was compared with that of the auscultated acceleration test (AAT) in predicting perinatal outcomes. The AAT is a more easily administered test than the NST, and, unlike the NST, does not use electronic fetal monitors. Study subjects were 205 women with singleton pregnancies greater than 34 weeks' gestation, whose delivery occurred within 7 days of receiving antepartum testing by NST at Johns Hopkins Hospital. The AAT yielded better prediction of poor perinatal outcomes than the NST. The NST, however, was a significantly better predictor of favorable outcomes than the AAT. The AAT has the potential to affect perinatal care if false positive results can be decreased through further research.

Population differences of fetal biophysical and behavioral characteristics.

Population differences in nonstress test reactivity have been reported with a threefold increase in the likelihood of nonreactive nonstress tests observed in black fetuses as compared with white fetuses. We analyzed fetal behavioral states and fetal heart rates in 14 black and 15 white fetuses at term to explain this observed difference in nonstress test reactivity. Two-hour Doppler and real-time ultrasonographic examination of each patient revealed no differences in percent time spent in the four behavioral states between the two populations. A 9.5 beats/min difference between black and white fetuses was found. The higher baseline heart rate of the black fetuses persisted in each behavioral state and may affect nonstress test reactivity because of rate-dependent decreases in short-term variability and rate-dependent limitations of maximal acceleration amplitude.

Fetal movement during labor.

The prognostic significance of antepartum fetal movement is well known; therefore it may be a variable in intrapartum fetal well-being. We report the simultaneous observation of fetal movement with fetal heart rate and uterine contractions by processed Doppler actograph signals during spontaneous labor of 22 normal women with normal fetal outcome. The mean percent incidence of fetal movement during labor was 17.3%. The percentage occurring during uterine contractions was 65.9%. Of all uterine contractions, 89.8% were associated with fetal movement. The proportion of time the fetus spent moving during uterine contractions (21.4%) was higher than between uterine contractions (12.9%). Uterine contractions associated with fetal movement were significantly longer than those not associated with fetal movement (p less than 0.0001). Mean percent incidence of fetal movement did not differ significantly between latent and active-phase labor. This study demonstrates a clear relationship between fetal movement and uterine contractions in labor.

Antepartum fetal assessment. A nurse-midwifery perspective.

This article provides an in-depth review of the most current antepartum fetal assessment techniques. Included in this review are both low- and high-technology methods, such as fetal movement counting, nonstress tests, vibroacoustic stimulation, auscultated acceleration tests, contraction stress tests, amniotic fluid index, biophysical profiles, and Doppler velocimetry. The interpretation of antepartum testing using screening test validity concepts is addressed, as is the current and emerging role of the nurse-midwife in fetal assessment. By integrating content on maternal and fetal physiology, including a critical review of current literature, together with relevant clinical information, including protocols, this article provides a useful guide to fetal assessment for nurse-midwives.