Mode of delivery and subsequent fertility.

STUDY QUESTION: When compared with vaginal delivery, is Cesarean delivery associated with reduced childbearing, a prolonged inter-birth interval or infertility? SUMMARY ANSWER: Women whose first delivery was by Cesarean section were not significantly different from those who delivered vaginally with respect to subsequent deliveries, inter-birth interval or infertility after delivery. WHAT IS ALREADY KNOWN: Some studies have suggested that delivery by Cesarean section reduces subsequent fertility, while others have reported no association. STUDY DESIGN, SIZE, DURATION: This was a planned secondary analysis of the Mothers' Outcomes After Delivery study, a longitudinal cohort study. This analysis included 956 women with 1835 deliveries, who completed a study questionnaire at 6-11 years (median [interquartile range]: 8.1 [7.1, 9.8]) after their first delivery. PARTICIPANTS/MATERIALS, SETTING, METHODS: Exclusion criteria regarding the first birth were: maternal age <15 or >50 years, delivery at <37 weeks gestation, placenta previa, multiple gestation, known fetal congenital abnormality, stillbirth, prior myomectomy and abruption. Of the 956 women included, the first delivery was by Cesarean section for 534 women and by vaginal birth for 422 women. Infertility was self-reported. To compare maternal characteristics by mode of first delivery, P-values were calculated using Fisher's exact test or Pearson's χ(2) test for categorical variables and a Kruskall-Wallis test for continuous variables. We also considered whether, across all deliveries to date, a prior Cesarean is associated with decreased fertility. In this analysis, self-reported infertility after each delivery (across all participants) was considered as a function of one or more prior Cesarean births, using generalized estimating equations to control for within-woman correlation. MAIN RESULTS AND THE ROLE OF CHANCE: No differences were observed between the Cesarean and vaginal groups (for first delivery) with respect to infertility after their most recent delivery (7 versus 6%, P = 0.597), the interval between their first and second births (30.8 versus 30.6 months, P = 0.872), or multiparity (75 versus 76%, P = 0.650). Across all births, a history of Cesarean delivery was not significantly associated with infertility (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.64-1.26). Women who reported infertility prior to their first delivery were significantly more likely to report infertility after each subsequent delivery (OR, 5.16; 95% CI, 3.60-7.39). LIMITATIONS, REASONS FOR CAUTION: Due to the use of self-reported infertility, the fertility status of some participants may be misclassified. Also, the small sample size may result in insufficient power to detect small differences between groups. Finally, a relatively high proportion of our participants were over age 35 at the time of first delivery (26%) and highly educated (37% with graduate degrees), which may indicate that our population may not be generalizable. WIDER IMPLICATIONS OF THE FINDINGS: While some prior studies have shown decreased family size among women who deliver by Cesarean, our results suggest that the rate of infertility is not different after Cesarean compared with vaginal birth. Our findings should be reassuring to women who deliver by Cesarean section. STUDY FUNDING/COMPETING INTERESTS: This study was funded by the US National Institutes of Health (NIH, R01-HD056275). No competing interests are declared. TRIAL REGISTRATION NUMBER: N/A.

Prescriptive authority for advanced practice nurses: current and future perspectives.

PURPOSE: To present an overview of the issues related to prescriptive authority and advanced practice nurses (APNs) in oncology. DATA SOURCES: Professional journals and books, print media, and professional and government releases. DATA SYNTHESIS: Discussion of issues related to complex political, educational, economic, and healthcare environmental factors. Strategies to achieve increased recognition for APN prescriptive authority include increasing APNs' knowledge about the effects of the political process on prescriptive authority, educating legislators and consumers, promoting standardization of pharmacology curricula, and encouraging formation of coalitions. CONCLUSIONS: Failure to pass a national healthcare plan, escalating managed-care markets, and the reform efforts of individual states to forge their own healthcare initiatives will challenge the APN's ability to practice and prescribe. IMPLICATIONS FOR NURSING PRACTICE: The subject of prescriptive authority highlights the controversies and debates that APNs encounter in a dynamic healthcare environment. These include the complexity of state-to-state regulations, non-nursing professions making key decisions regarding scope of practice and prescriptive authority, and the challenge for APNs to carve out new roles while overcoming state regulatory inconsistencies and market-reform barriers. If not resolved, these issues will continue to prevent qualified APNs from providing appropriate and comprehensive care to patients with cancer.

Healthcare reform: past and future.

PURPOSE: To review changes in the healthcare delivery system and project the challenges that practitioners and consumers will face in a reformed environment. DATA SOURCES: Professional journals and books, print media, and government releases. DATA SYNTHESIS: Analysis of projected reform plans, discussions of issues related to complex social, economic, and political factors, and considerations for practice changes for oncology nurses. CONCLUSIONS: The pending dominance of healthcare delivery through managed-care systems will challenge oncology care providers and consumers. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses must identify the opportunities, master the challenges, and adapt to the trends of the reformed healthcare system. The delivery of long-term care to senior citizens, patients with AIDS, and individuals from diverse cultures will shift to more community, ambulatory, and rural managed-care settings. Oncology nursing practice in these environments raises questions about prevention and screening, diagnosis, treatment, follow-up, alternative care, and research. Oncology nurses, especially advanced practice nurses, will play a pivotal role in reshaping the delivery of patient care and in designing the future of their profession.

The diagnosis and management of hypomagnesemia: a unique treatment approach and case report.

Hypomagnesemia is a common but frequently overlooked electrolyte disorder that occurs as part of a complex metabolic profile. It often is associated with a spectrum of nonspecific symptoms secondary to other electrolyte deficiencies. These symptoms then are associated with the primary illness, thereby masking the presence of this disorder. In most clinical situations, magnesium deficiency is transitory and responds well to short-term supplementation. Certain populations of patients with cancer may have an increased risk of developing severe hypomagnesemia requiring continued supplementation; patient populations receiving aminoglycoside antibiotics or cisplatin therapy are considered to be high-risk groups. This paper describes the causes, signs, and symptoms of chronic hypomagnesemia; patient populations at risk of developing this disorder; and a unique treatment approach using a subcutaneous pump infusion system. A case study illustrates the complexity of clinical and nursing management of this disorder.