Mavis Schorn

Factors that Influence Midwives to Serve as Preceptors: An American College of Nurse-Midwives Survey

INTRODUCTION Projected shortages in the primary care workforce underlie a need for more womens health care providers. In order to prepare more midwives to address this deficit, educators require additional clinical placement sites for students. The purpose of this study was to determine factors that influence practicing midwives to serve as preceptors. METHODS An e-mail invitation to participate in an online survey was sent to 7658 current and lapsed members of the American College of Nurse- Midwives (ACNM), who provided ACNM with a valid e-mail address. The survey assessed factors that enabled or were barriers for midwifery preceptors. Forced-choice questions were analyzed using descriptive statistics. Participant comments were analyzed using qualitative descriptive methods. RESULTS There were a total of 1517 surveys completed, for a response rate of 19.8%. Participants were primarily certified nurse-midwives (96.0%) who were in clinical practice (83.9%), with 78.0% in full-scope clinical practice. Participants represented all geographic regions of the United States. The majority of the participants indicated they or someone in their practice could precept a midwifery student. A commitment to the midwifery profession was the most commonly identified motivating factor (58.5%). Larger practices were more likely to precept midwifery students and to accept more than one student at a time. The most frequently identified barrier to precepting was the need to maintain a high patient volume (6.9%). Write-in comments were provided by approximately 500 participants and coded into 9 themes: payment, barriers to precepting, incentives, student characteristics, mechanisms for placement, communication, giving back, preceptor qualifications, and professional issues. DISCUSSION There is a strong commitment from preceptors to give back to the profession through the teaching of the future generation of midwives. Many of the barriers to precepting could be addressed by ACNM, the Accreditation Commission for Midwifery Education, and individual midwifery education programs.

Volume replacement following severe postpartum hemorrhage.

Severe postpartum hemorrhage (PPH) can be defined as a blood loss of more than 1500 mL to 2500 mL. While rare, severe PPH is a significant contributor to maternal mortality and morbidity in the United States and throughout the world. Due to the maternal hematologic adaptation to pregnancy, the hypovolemia resulting from hemorrhage can be asymptomatic until a large amount of blood is lost. Rapid replacement of lost fluids can mitigate effects of severe hemorrhage. Current evidence on postpartum volume replacement suggests that crystalloid fluids should be used only until the amount of blood loss becomes severe. Once a woman displays signs of hypovolemia, blood products including packed red blood cells, fresh frozen plasma, platelets, and recombinant factor VIIa should be used for volume replacement. Overuse of crystalloid fluids increases the risk for acute coagulopathy and third spacing of fluids. A massive transfusion protocol is one mechanism to provide a rapid, consistent, and evidence-based team response to this life-threatening condition.

Cesarean Outcomes in US Birth Centers and Collaborating Hospitals: A Cohort Comparison.

Introduction: High rates of cesarean birth are a significant health care quality issue, and birth centers have shown potential to reduce rates of cesarean birth. Measuring this potential is complicated by lack of randomized trials and limited observational comparisons. Cesarean rates vary by provider type, setting, and clinical and nonclinical characteristics of women, but our understanding of these dynamics is incomplete. Methods: We sought to isolate labor setting from other risk factors in order to assess the effect of birth centers on the odds of cesarean birth. We generated low‐risk cohorts admitted in labor to hospitals (n = 2527) and birth centers (n = 8776) using secondary data obtained from the American Association of Birth Centers (AABC). All women received prenatal care in the birth center and midwifery care in labor, but some chose hospital admission for labor. Analysis was intent to treat according to site of admission in spontaneous labor. We used propensity score adjustment and multivariable logistic regression to control for cohort differences and measured effect sizes associated with setting. Results: There was a 37% (adjusted odds ratio [OR], 0.63; 95% confidence interval [CI], 0.50‐0.79) to 38% (adjusted OR, 0.62; 95% CI, 0.49‐0.79) decreased odds of cesarean in the birth center cohort and a remarkably low overall cesarean rate of less than 5% in both cohorts. Discussion: These findings suggest that low rates of cesarean in birth centers are not attributable to labor setting alone. The entire birth center care model, including prenatal preparation and relationship‐based midwifery care, should be studied, promoted, and implemented by policy makers interested in achieving appropriate cesarean rates in the United States.

Labor Dystocia: Uses of Related Nomenclature

INTRODUCTION Labor dystocia (slow or difficult labor or birth) is the most commonly diagnosed aberration of labor and the most frequently documented indication for primary cesarean birth. Yet, dystocia remains a poorly specified diagnostic category, with determinations often varying widely among clinicians. The primary aims of this review are to 1) summarize definitions of active labor and dystocia, as put forth by leading professional obstetric and midwifery organizations in world regions wherein English is the majority language and 2) describe the use of dystocia and related terms in contemporary research studies. METHODS Major national midwifery and obstetric organizations from qualifying United Nations-member sovereign nations and international organizations were searched to identify guidelines providing definitions of active labor and dystocia or related terms. Research studies (2000-2013) were systematically identified via PubMed, MEDLINE, and CINAHL searches to describe the use of dystocia and related terms in contemporary scientific publications. RESULTS Only 6 organizational guidelines defined dystocia or related terms. Few research teams (n = 25 publications) defined dystocia-related terms with nonambiguous clinical parameters that can be applied prospectively. There is heterogeneity in the nomenclature used to describe dystocia, and when a similar term is shared between guidelines or research publications, the underlying definition of that term is sometimes inconsistent between documents. DISCUSSION Failure to define dystocia in evidence-based, well-described, clinically meaningful terms that are widely acceptable to and reproducible among clinicians and researchers is concerning at both national and global levels. This failure is particularly problematic in light of the major contribution of this diagnosis to primary cesarean birth rates.

Facilitators of prenatal care access in rural Appalachia

BACKGROUND There are many providers and models of prenatal care, some more effective than others. However, quantitative research alone cannot determine the reasons beneficial models of care improve health outcomes. Perspectives of women receiving care from effective clinics can provide valuable insight. METHODS We surveyed 29 women receiving care at a rural, Appalachian birth center in the United States with low rates of preterm birth. Semi-structured interviews and demographic questionnaires were analyzed using conventional qualitative content analysis of manifest content. FINDINGS Insurance was the most common facilitator of prenatal access. Beneficial characteristics of the provider and clinic included: personalized care, unrushed visits, varied appointment times, short waits, and choice in the type and location of care. CONCLUSION There is a connection between compassionate and personalized care and positive birth outcomes. Women were willing to overcome barriers to access care that met their needs. To facilitate access to prenatal care and decrease health disparities, healthcare planners, and policy makers need to ensure all women can afford to access prenatal care and allow women a choice in their care provider. Clinic administrators should create a welcoming clinic environment with minimal wait time. Unrushed, woman-centered prenatal visits can increase access to and motivation for care and are easily integrated into prenatal care with minimal cost.

Facilitating Access to Prenatal Care Through an Interprofessional Student-Run Free Clinic

INTRODUCTION Addressing the persistent challenge of inadequate prenatal care requires innovative solutions. Student-run free health centers are poised to rise to this challenge. The Shade Tree Clinic Early Pregnancy Program, jointly operated by university medical and nursing programs, functions as an ongoing access-to-care portal for pregnant women without health insurance. The clinic is run by medical students and nurse-midwifery students and uses a service-based learning model that allows students to work and learn in supervised, interprofessional teams while providing evidence-based prenatal care. METHODS All data reported in this paper were obtained from a retrospective chart review of women served by the prenatal clinic. These data are descriptive in nature, and include the patient demographics and services provided by the clinic to 152 women between the years of 2010-2013. RESULTS During this time period, the clinic served a demographically diverse clientele. Approximately half lacked documentation of legal immigration status. The majority of women seeking care were in their first trimester of pregnancy and had previously given birth. Several women had medical or obstetric complications that required timely referral to specialist care; and many women received treatment for infection and other primary care concerns. DISCUSSION Shade Tree Clinic provides the basic components of prenatal care and assists women with other medical needs. Women also receive help when applying for and accessing public maternity insurance, and the clinic facilitates entry to any necessary specialist care while that insurance is processed. In many cases, necessary and time-sensitive care would be delayed if Shade Tree Clinics prenatal services were not available. In addition, the clinic presents a valuable opportunity for interprofessional socialization, increased respect, and improved collaboration between students in different but complementary professions, which is an important experience while we move to meet national goals for interprofessional care among health professionals. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Labor Dystocia: A Common Approach to Diagnosis

Contemporary labor and birth population norms should be the basis for evaluating labor progression and determining slow progress that may benefit from intervention. The aim of this article is to present guidelines for a common, evidence-based approach for determination of active labor onset and diagnosis of labor dystocia based on a synthesis of existing professional guidelines and relevant contemporary publications. A 3-point approach for diagnosing active labor onset and classifying labor dystocia-related labor aberrations into well-defined, mutually exclusive categories that can be used clinically and validated by researchers is proposed. The approach comprises identification of 1) an objective point that strictly defines active labor onset (point of active labor determination); 2) an objective point that identifies when labor progress becomes atypical, beyond which interventions aimed at correcting labor dystocia may be justified (point of protraction diagnosis); and 3) an objective point that identifies when interventions aimed at correcting labor dystocia, if used, can first be determined to be unsuccessful, beyond which assisted vaginal or cesarean birth may be justified (earliest point of arrest diagnosis). Widespread adoption of a common approach for diagnosing labor dystocia will facilitate consistent evaluation of labor progress, improve communications between clinicians and laboring women, indicate when intervention aimed at speeding labor progress or facilitating birth may be appropriate, and allow for more efficient translation of safe and effective management strategies into clinical practice. Correct application of the diagnosis of labor dystocia may lead to a decrease in the rate of cesarean birth, decreased health care costs, and improved health of childbearing women and neonates.

On the same page: a novel interprofessional model of patient-centered perinatal consultation visits

Objective:To plan and implement an interprofessional collaborative care clinic for women in midwifery care needing a consultation with a maternal–fetal medicine specialist.Study Design:A community-engaged design was used to develop a new model of collaborative perinatal consultation, which was tested with 50 women. Participant perinatal outcomes and semistructured interviews with 15 women (analyzed using qualitative descriptive analysis) and clinic providers were used to evaluate the model.Results:Participant perinatal outcomes following a simultaneous consultation visit involving a nurse-midwife and maternal–fetal medicine specialist were similar to practice and hospital averages. Women’s comments on their experience were positive and had the theme ‘on the same page’ with six subcategories: clarity, communication, collaboration, planning, validation and ‘above and beyond’. Providers also were pleased with the model.Conclusion:A simultaneous consultation involving the woman, a nurse-midwife and a maternal–fetal medicine specialist improved communication and satisfaction among women and providers.

Team-Based Learning for Midwifery Education

INTRODUCTION Many US health care and education stakeholder groups, recognizing the need to prepare learners for collaborative practice in complex care environments, have called for innovative approaches in health care education. Team-based learning is an educational method that relies on in-depth student preparation prior to class, individual and team knowledge assessment, and use of small-group learning to apply knowledge to complex scenarios. Although team-based learning has been studied as an approach to health care education, its application to midwifery education is not well described. METHODS A masters-level, nurse-midwifery, didactic antepartum course was revised to a team-based learning format. Student grades, course evaluations, and aggregate American Midwifery Certification Board examination pass rates for 3 student cohorts participating in the team-based course were compared with 3 student cohorts receiving traditional, lecture-based instruction. RESULTS Students had mixed responses to the team-based learning format. Student evaluations improved when faculty added recorded lectures as part of student preclass preparation. Statistical comparisons were limited by variations across cohorts; however, student grades and certification examination pass rates did not change substantially after the course revision. Although initial course revision was time-consuming for faculty, subsequent iterations of the course required less effort. DISCUSSION Team-based learning provides students with more opportunity to interact during on-site classes and may spur application of knowledge into practice. However, it is difficult to assess the effect of the team-based learning approach with current measures. Further research is needed to determine the effects of team-based learning on communication and collaboration skills, as well as long-term performance in clinical practice. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Unexpected birth in the emergency department: the role of the advanced practice nurse.

Emergency department (ED) births are relatively uncommon, but when they occur, the advanced practice nurse is in a unique position to assist the mother through unexpected vaginal delivery in the ED. The purpose of this article is to guide the advanced practice nurse through the process of care for a woman giving birth in the emergency department. Anticipation, preparation, “the catch,” the newborn, the placenta, stabilization, and transport are the individual steps reviewed in this article. The focus of this manuscript is also to discuss the management of a mother and neonate during and following an unexpected vaginal birth.