Contemporary Nurse-Midwifery Care in Colorado: A Survey of Certified Nurse-Midwife Practices in Hospital and Community Settings.

Lack of access to birth facilities and maternity care providers has contributed to rising US maternal mortality and morbidity rates, especially among women in rural areas. Evidence supports the increased use of midwives as a potential solution for access-to-care issues. This observational survey was conducted to identify the practice environment for Certified Nurse-Midwives® in Colorado for the purpose of informing future workforce expansion. Study results indicate that midwives provide services aligned with the midwifery model of care and have mostly autonomous practice in hospitals where midwifery practices are already established. However, there is limited use of midwives, as fewer than half of Colorado's 69 birthing hospitals have midwifery practices, and financial constraint created by low Medicaid reimbursement could be a limiting factor in establishing new midwifery practices. Policy recommendations based on survey results include (a) support for midwifery education and workforce development, (b) removal of hospital-level restrictions for privileges of midwives, and (c) consideration for public payment models that promote expansion of midwifery practices.

Student Interviews Exploring the Influence of the Coronavirus Pandemic on Graduate Nursing Education.

Introduction: Advanced practice nurses are needed to fill the primary healthcare gap in the United States. Advanced practice/graduate nursing students were profoundly affected by the coronavirus pandemic in ways that may impact their educational experience. Objective: The objective of this study was to explore the influence of the coronavirus pandemic on the educational experience of graduate nursing students. Methods: An exploratory descriptive qualitative study using semistructured video conferencing interviews of 11 graduate nursing students at one university in the United States was conducted during July 2020. Data were explored using theme analysis. Results: Four themes expressing the pandemic's impact on graduate student experience were identified: Alteration in human connections; Agility in action; Collaborative construction of change; and Metamorphosis emerging from disruption. The pandemic brought an alteration in how students connected with faculty, other students, and family. Many faculty and students responded with agility to the new mandates for social distancing. The students and faculty worked together to construct changes needed to provide the students with the required components of graduate education. These factors together created a metamorphosis in the functioning of the institution, breaking through hierarchical barriers in academia. Conclusion: The disruption in graduate nursing education due to the pandemic led to opportunities, including swift faculty innovation, a collaborative spirit between faculty and students, and new appreciation for connections with faculty and fellow students. Continuing intentional implementation of these opportunities would benefit students' experiences moving forward.

Multicenter Study Evaluating Nitrous Oxide Use for Labor Analgesia at High- and Low-Altitude Institutions.

BACKGROUND: Nitrous oxide (N2O) has been used nationally as an analgesic in many clinical settings. While neuraxial analgesia is still the most commonly used labor analgesic in the United States, there is increasing use of N2O in labor. Given the reduction in the partial pressure of gases at a higher altitude, N2O has been reported to have reduced analgesic properties. However, there is no study to date evaluating the impact of altitude on labor analgesia and N2O. METHODS: We conducted a multicenter retrospective data analysis of a N2O registry collected from 4 institutions over a 3-year period. We compared the impact of altitude on 50% N2O administration for labor analgesia, conversion rates to another analgesic modality, as well as collected side effect frequencies and conversion predictors. Multivariable regression models were used to compare clinical characteristics and outcomes between parturients at high and low altitudes, while adjusting for race, ethnicity, education, and age (logistic and linear regressions for categorical and quantitative outcomes, respectively). RESULTS: A total of 1856 laboring parturients (age 18-50) were included in the analysis. The odds of converting from 50% N2O to another analgesic modality had no statistically significant difference between high- versus low-altitude institutions (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI], 0.90-1.42; P = .3). Yet, when parturients at low altitude converted from N2O, they were more likely (aOR, 3.03; 95% CI, 1.59-5.88) to choose neuraxial analgesia instead of another analgesic modality when compared to high-altitude parturients. This is possibly due to higher epidural rates at the low-altitude institutions. When parturients at high altitude did convert into another modality, they were more likely (aOR, 2.19; 95% CI, 1.14-4.21) to convert due to inadequate pain relief compared to low-altitude parturients; however, missing data may have affected this finding. Laboring individuals at low altitude were significantly more likely to experience side effects (aOR, 2.13; 95% CI, 1.45-3.12). Those requiring labor augmentation, assisted vaginal, or cesarean delivery converted to neuraxial analgesia significantly more often than those that delivered via spontaneous vaginal delivery (P < .05) in both high- and low-altitude groups. CONCLUSIONS: This is the first study evaluating 50% N2O as a labor analgesic at high altitude. As expected, we found lower side effects at high altitude, likely due to the lower partial pressure of N2O. However, there was not a statistically significant increase in conversion from N2O to another analgesic modality at high altitude and no clinically significant differences in neonatal outcomes.

Graduate nursing student stressors during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic profoundly impacted graduate nursing students at work, home, and school. Stress can influence the ability to focus, study, and may delay continuation in graduate school. PURPOSE: The purpose of this study was to identify the stressors of graduate nursing students during the pandemic. METHOD: A prospective, descriptive, online survey design was used to identify graduate nursing student stressors during the pandemic at one educational institution in the United States. Questions related to employment, COVID-19 exposure, institutional support, future graduate plans were summarized for the total sample and stratified by program (MS, DNP, PhD). Changes in a total stress score were evaluated pre and post onset of the COVID-19 pandemic. RESULTS: A total of 222 graduate nursing students completed the survey. The vast majority of students were employed before the pandemic and a significant decrease in employment occurred during the pandemic (97.3% to 90.1%, p < .001). Overall stress increased (p < .001). The increased total stress was associated with students participating in clinical rotations (q = 0.024) and having a change in work hours (q = 0.022). CONCLUSIONS: Nursing schools need to address graduate student concerns during the pandemic, including having clear communication platforms and offering support services.

A Survey of Mental Health in Graduate Nursing Students during the COVID-19 Pandemic.

BACKGROUND: Elevated levels of stress, anxiety, and depression are common symptoms in graduate students pursuing a degree in the health care professions. The onset of the COVID-19 pandemic likely complicated these existing issues. PURPOSE: To confirm this hypothesis, researchers created a survey to examine the experiences of graduate nursing students during COVID-19. METHODS: Graduate nursing students (n = 222) completed the survey, which included 2 instruments: the Depression, Anxiety and Stress Scale (DASS-21) and the Impact of Events Scale (IES-R). RESULTS: Nearly 25% of students expressed moderate to extremely severe levels of negative emotional states on the DASS-21, and 23.8% of students scored within the area of clinical concern for the presence of posttraumatic stress disorder on the IES-R. CONCLUSIONS: Understanding levels of mental health and associated factors that may contribute to changes can assist administration, faculty, and staff in targeting resources and interventions to support graduate nursing students to continue their education.

Nitrous Oxide Use During Labor: Satisfaction, Adverse Effects, and Predictors of Conversion to Neuraxial Analgesia.

INTRODUCTION: Women desire safe and effective choices for pain management during labor. Currently, neuraxial and opioid analgesia are the most common methods used in the United States. The purpose of this study was to investigate demographic characteristics, safety, and satisfaction in a cohort of parturients who used inhaled nitrous oxide (N2 O) analgesia and to determine predictors of conversion from N2 O to neuraxial analgesia. METHODS: This was a prospective chart review study. Individuals aged at least 18 years who used inhaled N2 O during the first or second stage of labor between March 1, 2016, and July 23, 2017, on the labor and delivery unit of one academic medical center (N = 463) and their neonates were included. Data describing maternal and neonatal factors are reported. Logistic regression and chi-square tests were used to model the effects of oxytocin augmentation, labor induction, parity, prior cesarean birth, pre-N2 O cervical dilatation, and post-N2 O cervical dilatation on the odds of conversion from N2 O to neuraxial analgesia. RESULTS: In this cohort, 31% who chose N2 O for analgesia did not convert to any other analgesic method. Significant positive predictors for conversion from N2 O to neuraxial analgesia included labor induction (odds ratio [OR], 2.9; 95% CI, 1.7-5.0), oxytocin augmentation (OR, 3.1; 95% CI, 1.6-6.0), and labor after cesarean (OR, 6.4; 95% CI, 2.5-16.5). Multiparity (OR, 0.4; 95% CI, 0.2-0.6) and post-N2 O cervical dilatation (OR, 0.8; 95% CI, 0.7-0.9) were negative predictors. Adverse effects related to N2 O use during labor were rare (8%) and were not a significant reason for conversion to neuraxial analgesia. Parturients had moderately high satisfaction with N2 O for pain management (11-point scale, mean [SD], 7.4 [2.9]). Five-minute Apgar scores were 7 or greater in 97.8% of the newborns. DISCUSSION: Understanding predictors of conversion from inhaled N2 O to neuraxial analgesia may assist perinatal care providers in their discussions with women about analgesia options during labor. N2 O is a useful, safe option for labor analgesia in the United States.

Using the Technology Acceptance Model to Develop StartSmart: mHealth for Screening, Brief Intervention, and Referral for Risk and Protective Factors in Pregnancy.

INTRODUCTION: Technology decision support with tailored patient education has the potential to improve maternal and child health outcomes. The purpose of this study was to develop StartSmart, a mobile health (mHealth) intervention to support evidence-based prenatal screening, brief intervention, and referral to treatment for risk and protective factors in pregnancy. METHODS: StartSmart was developed using Davis' Technology Acceptance Model with end users engaged in the technology development from initial concept to clinical testing. The prototype was developed based upon the current guidelines, focus group findings, and consultation with patient and provider experts. The prototype was then alpha tested by clinicians and patients. Clinicians were asked to give feedback on the screening questions, treatment, brief motivational interviewing, referral algorithms, and the individualized education materials. Clinicians were asked about the feasibility of using the materials to provide brief intervention or referral to treatment. Patients were interviewed using the think aloud technique, a cognitive engineering method used to inform the design of mHealth interventions. Interview questions were guided by the Screening, Brief Intervention, Referral to Treatment theory and attention to usefulness and usability. RESULTS: Expert clinicians provided guidance on the screening instruments, resources, and practice guidelines. Clinicians suggested identifying specific prenatal visits for the screening (first prenatal visit, 28-week visit, and 36-week visit). Patients reported that the tablet-based screening was useful to promote adherence to guidelines and provided suggestions for improvement including more information on the diabetic diet and more resources for diabetes. During alpha testing, participants commented on navigability and usability. Patients reported favorable responses about question wording and ease of use. DISCUSSION: Clinicians reported the use of mHealth to screen and counsel pregnant patients on risk and protective factors facilitated their ability to provide comprehensive care.

A Comparative Workforce Study of Midwives Practicing in the State of Texas.

INTRODUCTION: Access to quality care is a problem in Texas, an ethnically diverse state with large birth numbers. The state has over 300 areas designated as medically underserved, and a severe lack of obstetricians and midwives. Minimal data exist on midwifery's contribution, and no known study compares the work environment and clinical practice of the 2 state-recognized midwifery paths, licensed midwives (LMs) and certified nurse-midwives (CNMs). The purpose of this study was to determine the differences in practice by CNMs and LMs, the latter of whom are generally certified professional midwives. The specific aims were to 1) describe the differences in demographic and employment characteristics of CNMs and LMs, 2) identify the geographic areas and population groups served by CNMs and LMs, and 3) compare the nature and scope of CNM and LM clinical practices. METHODS: Online parallel surveys of Texas LMs and CNMs were conducted in December 2015 and January 2016. The REDCap data management system housed the 123- and 125-item surveys for LMs and CNMs, respectively, addressing demographics, populations served, and clinical practice. A comparative statistical analysis, using Fisher's exact test, Pearson's chi-squared test, and Independent Samples t-tests, was performed. RESULTS: The survey response rates of LMs and CNMs were 35.4% (n = 75) and 31.9% (n = 143), respectively. Differences in demographics, employment status, workload, scope of practice, risk assessment, time-based care management, and technology use were observed. DISCUSSION: Findings represent the first attempt to describe the Texas midwifery workforce. In a large state with health care provider shortages, this step is pivotal in addressing strategies for providing services for women and infants. This groundwork can provide the foundation for including midwifery in a state health plan.

Nature and scope of certified nurse-midwifery practice: A workforce study.

AIMS AND OBJECTIVES: To describe the nature and scope of nurse-midwifery practice in Texas and to determine legislative priorities and practice barriers. BACKGROUND: Across the globe, midwives are the largest group of maternity care providers despite little known about midwifery practice. With a looming shortage of midwives, there is a pressing need to understand midwives' work environment and scope of practice. DESIGN: Mixed methods research utilising prospective descriptive survey and interview. METHODS: An online survey was administered to nurse-midwives practicing in the state of Texas (N = 449) with a subset (n = 10) telephone interviewed. Descriptive and inferential statistics and content analysis was performed. RESULTS: The survey was completed by 141 midwives with eight interviewed. Most were older, Caucasian and held a master's degree. A majority worked full-time, were in clinical practice in larger urban areas and were employed by a hospital or physician group. Care was most commonly provided for Hispanic and White women; approximately a quarter could care for greater numbers of patients. Most did not clinically teach midwifery students. Physician practice agreements were believed unnecessary and prescriptive authority requirements restrictive. Legislative issues were typically followed through the professional organisation or social media sites; most felt a lack of competence to influence health policy decisions. While most were satisfied with current clinical practice, a majority planned a change in the next 3 to 5 years. CONCLUSIONS: An ageing midwifery workforce, not representative of the race/ethnicity of the populations served, is underutilised with practice requirements that limit provision of services. Health policy changes are needed to ensure unrestricted practice. RELEVANCE TO CLINICAL PRACTICE: Robust midwifery workforce data are needed as well as a midwifery board which tracks availability and accessibility of midwives. Educators should consider training models promoting long-term service in underserved areas, and development of skills crucial for impacting health policy change.

Common sleep disorders: management strategies and pregnancy outcomes.

Sleep disorders, prevalent in industrialized countries, are associated with adverse health outcomes such as hypertension, diabetes, and obesity. Disturbed sleep during pregnancy is frequently overlooked by health care providers, yet recent studies suggest there is an association between sleep disorders and adverse pregnancy outcomes, including preeclampsia, elevated serum glucose, depression, prolonged labor, and cesarean birth. Growing evidence indicates that the recognition and management of prenatal sleep disorders may minimize adverse pregnancy outcomes and improve maternal and fetal well-being. This focused review of prenatal sleep disturbance literature suggests there are 3 main sleep disorders of interest: breathing-related sleep disorders (ie, habitual snoring and obstructive sleep apnea), restless legs syndrome, and insomnia. These sleep disorders are common in pregnancy and have maternal and fetal consequences if left untreated. This article describes sleep disorders of pregnancy, elucidates their relationship with maternal and neonatal outcomes, and presents current evidence regarding diagnostic and management strategies.

Maternal obesity: improving pregnancy outcomes.

Approximately 30% of pregnant women are obese (body mass index [BMI] ≥ 30) and are at risk for adverse pregnancy outcomes. In this article, we review the literature on select obstetrical risks associated with maternal obesity and assess the recommended prevention and management strategies. The selected risks include infertility, fetal anomalies, gestational hypertensive diseases, gestational diabetes, intrauterine fetal death, cesarean birth, macrosomia, and long-term risks of adult disease for the fetus. The causes of these adverse outcomes include maternal body habitus, the proinflammatory state of obesity, and metabolic dysfunction. We also discuss how nurses, nurse practitioners, and nurse-midwives can make a difference in the prenatal care and immediate pregnancy outcomes of pregnant women with obesity and influence future health for these women and their children.

Sterilization decision making among medically at-risk obese pregnant women.

In this article, we describe a study using a qualitative, naturalistic grounded theory design to explore sterilization decision making by pregnant obese women. Semistructured interviews of women who intended to undergo sterilization at the time of delivery were conducted in the third trimester of pregnancy (n = 15) and again postpartum (n = 11). The decision for sterilization was based on personal criteria for family composition and the nature of each woman's relationship with her partner. The process of decision making began with developing a personal comfort with cessation of childbearing, followed by social confirmation, informing the provider, and then awaiting the procedure. Sterilization was seen as reversible, despite a desire for "something permanent." Obesity was rarely viewed as related to any part of the decision for or against sterilization, and was rarely discussed by providers. Participants made sterilization decisions in their personal and social contexts, and then shared the decision with their providers, whom they often perceived as challenging that decision.

Pregnancy outcome after transcervical hysteroscopic sterilization.

BACKGROUND: Hysteroscopic, transcervical sterilization involves placement of microinserts in tubal ostia. As with any contraceptive method, pregnancy can occur. This case reports the outcome when pregnancy occurred after microinsert placement. CASE: A multiparous woman presented at 16 weeks of gestation. Hysteroscopic sterilization was performed 2 years earlier, although a postprocedure hysterosalpingogram was not done to verify tubal occlusion. The patient had a normal-term pregnancy. Postpregnancy hysterosalpingogram revealed both microinserts were embedded in the uterine fundus and myometrium. CONCLUSION: This case demonstrates how pregnancy can occur after hysteroscopic microinsert placement and details how it might be avoided.

Essure: hysteroscopic sterilization.

Essure, a new female sterilization method approved by the US Food and Drug Administration, offers women a new option for controlling fertility. The technique is done without an incision, is hormone-free, and can be performed on an outpatient basis under local anesthesia. There are few or no side effects. It is important for providers to understand how the device works, appropriate candidates for use, and requirements for preplacement and postplacement management.