Sharon L. Holley

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.

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.

Facilitators of prenatal care in an exemplar urban clinic.

BACKGROUND Perinatal outcomes have complex causes that include biologic, maternal, structural, and societal components. We studied one urban nurse-led clinic serving women at risk for poor perinatal outcomes with superior pre-term birth rates (4%) when compared with the surrounding county (11.2%). AIM To explore womens perspectives of their interface with the clinic, staff, and providers to understand this exemplary model. METHODS A qualitative descriptive approach with semi-structured interviews as the primary data source. Participants (n=50) were recruited from an urban clinic in the Southeast United States designed to serve women of low socio-economic status or who are recent immigrants. FINDINGS Women greatly valued a personal connection with the nurse-midwives and staff, and felt this resulted in high-quality care. Convenient appointment times and the lack of wait for initial or subsequent appointments made care accessible. Participants reported the relaxed and helpful approach and attitudes of the office staff were essential components of their positive experience. Women valued unrushed visits to ask questions and receive information. In addition, participants felt that clinic staff were easy to reach. CONCLUSION While qualitative data cannot demonstrate causation, this study provides support that a compassionate and personalized approach to care motivates women to access needed services in pregnancy. Clinic staff are an essential component of the access process. Women overcame barriers to obtain personalized, culturally appropriate care provided by kind, competent practitioners. Clinic staff and practitioners should develop a connection with each woman by providing care that meets her physical, cultural, and personal needs.

Prevention of Vitamin K Deficiency Bleeding.

The risk that a newborn will develop vitamin K deficiency bleeding is 1700/100,000 (one out of 59) if vitamin K is not administered. When intramuscular vitamin K is administered, the risk of vitamin K deficiency bleeding is reduced to 1/100,000. While women may have misconceptions about vitamin K prophylaxis for their newborns, health care providers should be prepared with factual information. Prophylaxis is needed even for healthy newborns without risk factors for bleeding. Other forms of vitamin K supplementation, including oral administration of Food and Drug Administration-approved vitamin K preparations and maternal supplements during pregnancy or lactation, do not have the same effectiveness as the parenteral form. The formulations of vitamin K approved for use in the United States have not been associated with childhood leukemia or other childhood health problems. Care providers need to give accurate information to families regarding the risks and benefits of vitamin K prophylaxis. An interprofessional approach to education can be effective in increasing acceptance of vitamin K prophylaxis and decreasing the incidence of vitamin K deficiency bleeding. This article uses a case study approach to highlight common misconceptions about vitamin K prophylaxis and discuss a recent interprofessional collaboration to prevent vitamin K deficiency bleeding.

Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation: An Overview for Advanced Practice Clinicians

Historically, hospitals have credentialed and privileged health care providers using standards heavily weightedwith personal references and other subjective information. In 2008, the Joint Commission added 2 new standards, the Ongoing Professional Practice Evaluation (OPPE) and the Focused Professional Practice Evaluation (FPPE), for all health care providers credentialed and privileged within hospitals accredited by the Joint Commission. These providers include physicians, advanced practice registered nurses (APRNs), certified nursemidwives/certified midwives (CNM/CMs), and physician assistants (PAs).1 All hospitals are expected to have this process in place, and the OPPEs must be available for Joint Commission review during inspections and audits. Inspectors may additionally request the data and summaries used for collection of the OPPE/FPPE evaluations and may interview providers or department leadership regarding the process. The OPPE is a summary of ongoing data collected for the purpose of assessing a practitioner’s clinical competence and professional behavior. It is completed more than once a year in an ongoing cycle; however, it is left to the individual hospital to decide the cycle length. For example, one hospital may choose to perform an evaluation every 3 months, while another hospital may choose to perform an evaluation every 6 months. The intent is for hospitals to use the OPPE to evaluate providers’ performance data on an ongoing basis. More frequent evaluation allows for the timely correction of poor performance.2 The FPPE, however, is a time-limited and focused evaluation of practitioner competence with a specific privilege. There are several reasons for a focused evaluation. First, all new providers must have the FPPE completed 6 months from the date of hire. Providers also need a focused evaluationwhen the OPPE reveals any problem. In addition, an FPPE is appropriate when a provider begins to perform a newly acquired skill or when a particular skill has not been used for an extended period of time. The OPPE and the FPPE are recurring processes that fit into a cycle of credentialing that occurs regularly and drives privileges at a hospital3 (Figure 1). The Joint Commission requires these documents to be distinctly separate from an annual review performed by an employer. Although the assessment of competence should be a balance of subjective

A Planning Checklist for Interprofessional Consultations for Women in Midwifery Care

Team-based, interprofessional models of maternity care can allow women to receive personalized care based on their health needs and personal preferences. However, involvement of multiple health care providers can fragment care and increase communication errors, which are a major cause of preventable maternal morbidity and mortality. In order to improve communication within one health system, a community-engaged approach was used to develop a planning checklist for the care of women who began care with midwives but developed risks for poor perinatal outcomes. The planning checklist was constructed using feedback from women, nurses, midwives, and physicians in one interprofessional, collaborative network. In feasibility testing during 50 collaborative visits, the planning checklist provided a prompt to generate a comprehensive plan for maternity care and elucidate the rationale for interventions to women and future health care providers. In interviews after implementation of the checklist within a new collaborative format of prenatal physician consultations, women were pleased with the information received, and nurses, midwives, and physicians were positive about improved communication. This tool, developed with stakeholder input, was easy to implement and qualitatively beneficial to satisfaction and health system function. This article details the creation, implementation, and qualitative evaluation of the planning checklist. The checklist is provided and can be modified to meet the needs of other health systems.

Pregnancy-Associated Stroke

Cerebrovascular accident, or stroke, is the fourth leading cause of death for all women and the eighth leading cause of pregnancy-associated death. The physiologic changes of pregnancy increase the risk of cerebrovascular accident for women. With current incidence rates, a facility with 3300 births per year can anticipate caring for one woman with a pregnancy-related stroke at least every 2 years. All maternity care providers must be able to assess women experiencing stroke-like symptoms and initiate timely care to mitigate brain tissue damage, decrease long-term morbidity, and prevent mortality. The 2 main types of stroke, ischemic and hemorrhagic, have similar presenting symptoms but very different pathophysiology and treatment. This article reviews assessment and initial treatment of pregnant and postpartum women experiencing stroke and provides guidance for subsequent maternity and primary care to assist front-line perinatal care providers who may be the first to treat affected women or may resume primary care after diagnosis.

Teaching Labor Support: An Interprofessional Simulation.

Support for women during labor encompasses the continuous presence of a person who provides psychosocial, emotional, and physical support. Providing labor support to women in the intrapartum setting is a core midwifery competency and a clinical skill that midwifery students are expected to master. Instruction on labor support is a common objective in midwifery education intrapartum courses and skills labs, yet there is no standard for teaching this skill to midwifery students. Thus, in order to accomplish this objective, we created an interprofessional simulation on labor support that involves the use of a standardized patient, a written scenario, an interprofessional team of nursing and midwifery students, faculty observations, and a reflective debrief. The goals of the labor support simulation are to allow midwifery students the opportunity to practice intrapartum labor support techniques and interprofessional communication prior to entering the clinical setting. A postsimulation structured debrief allows for student learning and reflection. This article describes the design, planning, and implementation of this unique simulation experience. 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.