Caring for women in early labor: can we delay admission and meet women's needs?

Early labor poses challenges for women and their health care providers. Qualitative research shows that women may have a hard time determining when labor begins and when to seek care, are unprepared for the realities of this part of labor, find it difficult to manage early labor at home, and often desire admission before active labor. Yet a primary clinical management goal in early labor is the delay of admission until active labor. This is based on evidence that admission before active labor is associated with higher rates of cesarean birth and interventions such as oxytocin augmentation and epidural analgesia. The reasons for the higher rates of intervention are not known, but may include the effect of the hospital environment, inherent problems with the labor, misdiagnosis of active labor, provider impatience, and institutional policies not compatible with the care of women in early labor. Programs to decrease early admission have had mixed results. Thus, a tension exists between the goal of delaying admission until active labor in order to decrease the incidence of unnecessary interventions and women's difficulty with managing this part of labor at home. In this case report, the midwife provides a significant amount of care and support before admission through phone calls and outpatient visits; however, admission occurred prior to active labor. Supportive care continued in the hospital, and the labor and birth occurred with little intervention. Strategies that can be used to optimize the management and experience of early labor are presented.

Waterbirth: an integrative analysis of peer-reviewed literature.

INTRODUCTION: Despite a growing body of evidence for waterbirth safety, a myriad of political and cultural issues result in limited use in US hospitals compared to other developed nations. The purpose of this article is to critically analyze the evidence on maternal and neonatal outcomes of waterbirth to help inform evidence-based clinical practice in the United States. METHODS: A literature search was performed using electronic databases CINAHL, Ovid MEDLINE, PubMed, EMBASE, and PsycINFO. Thirty-eight studies, including 2 randomized controlled trials and 36 observational studies, were reviewed. Studies were conducted in 11 countries, mostly outside the United States. More than 31,000 waterbirths were described. RESULTS: Aggregate results suggest that waterbirth is associated with high levels of maternal satisfaction with pain relief and the experience of childbirth, and may increase the likelihood of an intact perineum. Waterbirth is associated with decreased incidence of episiotomy and severe perineal lacerations, and may contribute to reduced postpartum hemorrhage. Data indicate no difference in maternal or neonatal infection rates or nursery admissions after waterbirth. Neonatal mortality rates are low and similar after waterbirth and uncomplicated conventional birth. The calculated cord avulsion rate is 2.4 per 1000 waterbirths; it is unknown how this compares to conventional birth due to a lack of data that permits direct comparison. DISCUSSION: The majority of waterbirth research to date is observational and descriptive; thus, reported outcomes do not demonstrate causal associations. However, existing evidence is reassuring. Case-controlled studies have included thousands of women who gave birth underwater without an apparent increase in maternal or neonatal morbidity or mortality. Potential risks associated with waterbirth for women and neonates appear minimal, and outcomes are comparable to those expected in any healthy childbearing population.

Shoulder dystocia and postpartum hemorrhage simulations: student confidence in managing these complications.

INTRODUCTION: Simulation is an effective teaching strategy for educating health professionals. However, little is known about the effectiveness of simulations in midwifery education. The purpose of this project was to determine whether the use of high-fidelity simulations for the obstetric emergencies of shoulder dystocia and postpartum hemorrhage increases student confidence in managing these complications. METHODS: The participants were registered nurses enrolled in a graduate midwifery education program in the Southeastern United States. Student confidence in learning to manage shoulder dystocia and postpartum hemorrhage was studied in 2 groups of students. The control group (n = 10) received standard teaching methods consisting of discussion, watching a video, and low-fidelity teaching methods. The intervention group (n = 18) received a high-fidelity simulation learning experience. Student confidence was measured before and after each learning experience using a validated, 8-item, Likert-type scale. RESULTS: In the control group, student confidence did not significantly increase after a classroom discussion or low-fidelity simulation experience. Student confidence increased significantly (P < .01) after the high-fidelity simulation learning experiences. When the differences between the pretest and posttest scores were compared for the control and intervention groups, there was a moderate effect size (0.54) for the intervention group for the shoulder dystocia simulations and a large effect size (1.68) for the postpartum hemorrhage simulations. CONCLUSION: High-fidelity simulations for shoulder dystocia and postpartum hemorrhage significantly increased student confidence in managing these complications.

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.