Improving satisfaction with care and reducing length of stay in an obstetric triage unit using a nurse-midwife-managed model of care.

INTRODUCTION: A quality improvement project was initiated at a tertiary-care center in a suburban area of the northeastern United States to determine whether length of stay and patient satisfaction in an obstetric triage unit could be improved by using a certified nurse-midwife (CNM) to manage and organize care in the triage unit. METHODS: Patient satisfaction was measured using a previously validated instrument that consisted of 6 items using a 6-point Likert-type scale. The items measured patient satisfaction with: wait time for provider, information given, amount of time spent with provider, length of visit, overall care received, and overall triage experience. Patient satisfaction was measured before (n = 37) and after implementing CNM-managed care (n = 66) in an obstetrical triage unit. Length of stay in the triage unit was measured during standard care (n = 121) and after the implementation of CNM-managed care (n = 151) by recording the number of minutes women spent in the triage unit. RESULTS: Participants in the CNM-managed care group reported increased patient satisfaction with care in 5 of the 6 aspects of satisfaction that were measured, including wait time for provider (P = .01), time spent with provider (P = .01), length of visit (P = .04), overall care received (P = .04), and overall triage experience (P = .01). The length of stay was significantly shorter for the women in the CNM-managed group (mean = 94.7 minutes; standard deviation [SD] 50.1) than for the women in the standard care model (mean = 122 minutes; SD = 66.8; P < .01). DISCUSSION: The findings from this project suggest that a CNM-managed obstetric triage unit can improve satisfaction with care during the triage experience and reduce length of stay in the triage unit.

Prenatal omega-3 fatty acids: review and recommendations.

The influence of dietary omega-3 fatty acids on health outcomes is widely recognized. The adequate intake of omega-3 fatty acids docasahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) in particular can increase gestation length and improve infant cognitive and visual performance. Adequate levels of omega-3 fatty acids have also been shown to reduce the incidence of preterm birth in some populations. Research on prenatal omega-3 intake and other outcomes, such as preeclampsia and fetal growth restriction, is inconclusive. Women in the United States consume low levels of omega-3 fatty acids compared to omega-6 fatty acids; this dietary pattern is associated with poor health outcomes. Omega-3 fatty acids are found primarily in fish, yet many pregnant women avoid fish because of concerns about potential mercury and polychlorinated biphenyl contamination. It is important for prenatal care providers to assess women's diets for omega-3 fatty acid intake and ensure that pregnant women are consuming between 200 and 300 mg daily from safe food sources. Purified fish, algal oil supplements, and DHA-enriched eggs are alternative sources for pregnant women who do not eat fish.

Risk assessment and risk distortion: finding the balance.

Pregnancy and birth have been conceptualized as medically problematic, with all pregnant women considered at risk and in need of medical monitoring. Universal application of risk scoring and surveillance as preemptive strategies in an effort to reduce risk is now standard obstetric practice. Labeling women "high risk" can result in more unnecessary interventions and have negative psychologic sequelae. When perceived pregnancy risk is out of proportion to the real risk, and when risk management procedures are applied to all women with benefit for only a few, the use of technology in caring for pregnant women becomes normalized. A learned reliance on technology can diminish women's own authoritative knowledge of pregnancy and birth. This may also have the unintended consequence of contributing to birth fear, a phenomena becoming more widely recognized. Health care provider-patient communication about pregnancy risk can be presented in a manner that encourages informed compliance rather than informed choice. Evidence-based risk assessment is essential to providing optimal prenatal care. Using tools such as the Paling Palette can help health care providers present balanced and readily understood information about risk.

The confidence to practice midwifery: preceptor influence on student self-efficacy.

The imperative for midwifery educators is to transmit to their students midwifery's unique body of knowledge and hallmarks of care that guide midwifery practice. Concerns have been raised about the ability to maintain the unique aspects of midwifery practice in a culture where routine use of intervention prevails. A theory-practice gap may lead to fewer student midwives exposed to the perspective and practices of midwifery during their clinical education. Preceptor role modeling is important to developing student confidence, conceptualized as self-efficacy, to persist in the practice of midwifery hallmark behaviors, particularly under conditions that undermine these practices. This study examined student perceptions of preceptor behaviors of two midwifery hallmarks of practice: therapeutic presence and non-intervention in the absence of complication and student self-efficacy for performing these behaviors. Recent graduates of education programs accredited by the American College of Nurse-Midwives Division of Accreditation completed researcher-developed tools regarding perceptions of preceptor behaviors of therapeutic presence and non-intervention and their outcome expectancy and self-efficacy for the same behaviors. The results indicate that preceptor behaviors influence student confidence to perform hallmark behaviors. Student belief in the value of the hallmark to benefit women is the biggest predictor of self-efficacy for hallmark behaviors. Clinical and educational implications and directions for future research are discussed.

Midwifery management of prelabor rupture of membranes at term.

Spontaneous rupture of membranes before the onset of labor at term is commonly referred to as PROM (either premature or preterm rupture of membranes) and occurs in about 8% of term pregnancies. PROM is associated with an increased risk of infection. Many controversies exist regarding the optimal management of PROM, including the choice of induction or expectant management, use of digital vaginal exams, and routine administration of antibiotics. This article reviews the literature on PROM and illustrates some of the management issues encountered by presenting approaches used in three midwifery services.

Characterization of a cDNA encoding metallothionein 3 from cotton (Gossypium hirsutum L.).

A cDNA encoding metallothionein (MT) was isolated from a library constructed with poly A(+) RNA purified from 48 h etiolated cotton (Gossypium hirsutum L.) cotyledons. This cDNA encodes a deduced protein with 63 residues and a molecular weight of 6.3 kDa. The protein has 10 cysteines of which 4 are within the CXXCXCXXXXXC amino-terminus motif and six are within the CXCXXXCXCXXCXC carboxyl-terminus motif characteristic of the type III MT (MT3). The cotton MT3 protein sequence is 76.2, 69.8, 66.7, 60.3 and 33.5% identical to MT3 from Carica papaya, Rubus idaeus, Ribes nigrum, Citrus unshiu, and Gossypium hirsutum type I MT, respectively. A fusion protein was constructed by producing PCR primers for the 5' and 3' ends of the cotton MT3 cDNA and ligating the PCR product inframe at the 3' end of a bacterial glutathione S-transferase (GST) gene in the pGEX3 vector. The 5' PCR primer incorporated a segment of the cotton MT3 noncoding region, resulting in an addition of 9 residues to the MT3 (after Factor Xa digestion site) which increased the size of the expressed protein to 72 residues and 7.6 kDa. Expression of the 7.6 kDa protein in bacteria was confirmed by SDS-PAGE. Induction and accumulation of the GST-MT3 protein began inhibiting bacterial growth after 1 h. Addition of Cu (1 muM to 1 mM), 1 mM cysteine, or 1 mM cystine to the media did not rescue growth. Additionally, this protein was evaluated for its ability to bind Cd, Cu, Ni and Zn in the bacterial expression system. We found that cotton MT3 preferentially binds Cu.