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Importance: Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes., Objective: To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality., Design, Setting, and Participants: This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021., Interventions: Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group., Main Outcomes and Measures: There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery., Results: Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups., Conclusions and Relevance: In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT03360539.

About 12 000 women of childbearing age sustain spinal cord injuries each year in the United States. Around 2000 of these women become pregnant in a given year, yet few providers are aware of the interprofessional team approach needed to achieve a successful pregnancy with healthy outcomes for both mother and fetus. A family-centered approach by an experienced team can make the childbearing experience both safe and optimal for the maternal-fetal dyad. The challenges related to caring for women with spinal cord injury during pregnancy, including skin breakdown, urinary tract infections, respiratory compromise, bowel motility, depression/anxiety, preterm labor, and autonomic dysreflexia, are reviewed.

Most women with depression around the time of childbearing are not treated adequately, or at all. Clinical practice guidelines focus primarily on provision of information rather than on interaction factors. In this study, we explored clinician interactional style characteristics contributing to patient response to perinatal depression referral and treatment. Stratified purposeful sampling resulted in 23 participants selected by pregnancy, socioeconomic, and depression status. Participants completed semistructured interviews exploring their experiences with and preferences for clinician interactional style characteristics in the context of obstetrics-setting referral and delivery of depression treatment. Thematic analysis revealed a central theme related to interactional cues that influence women's reactions to clinical encounters, summarized by the question, "Can this person help me?" Women evaluated this question in four domains: feeling heard, developing trust in the clinician, perceiving technical competence in the clinician, and feeling that the intervention focus is effectively chosen and communicated. Our results imply that, in addition to informational factors, the way in which clinicians interact with patients about depression might strongly influence patient responses.

To determine whether a Nurse-Community Health Worker (CHW) home visiting team, in the context of a Medicaid enhanced prenatal/postnatal services (EPS), would demonstrate greater reduction of depressive symptoms and stress and improvement of psychosocial resources (mastery, self-esteem, social support) when compared with usual Community Care (CC) that includes Medicaid EPS delivered by professionals. Greatest program benefits were expected for women who reported low psychosocial resources, high stress, or both at the time of enrollment. Medicaid eligible pregnant women (N = 613) were randomly assigned to either usual CC or the Nurse-CHW team. Mixed effects regression was used to analyze up to five prenatal and postnatal psychosocial assessments. Compared to usual CC, assignment to the Nurse-CHW team resulted in significantly fewer depressive symptoms, and as hypothesized, reductions in depressive symptoms were most pronounced for women with low psychosocial resources, high stress, or both high stress and low resources. Outcomes for mastery and stress approached statistical significance, with the women in the Nurse-CHW group reporting less stress and greater mastery. Women in the Nurse-CHW group with low psychosocial resources reported significantly less perceived stress than women in usual CC. No differences between the groups were found for self-esteem and social support. A Nurse-CHW team approach to EPS demonstrated advantage for alleviating depressive symptoms in Medicaid eligible women compared to CC, especially for women at higher risk.

Approximately 7 million women in the United States become widows each year. It is not known how many women are pregnant at the time of their husband's death. This study describes the lived experience of widowhood during pregnancy as defined by 10 widows whose husbands were killed in the September 11, 2001 terrorist attacks or while they served in the US military during the Iraq and Afghanistan wars. Purposive sampling was used and data were generated using four core questions. The research methodology was phenomenology, and interviews were conducted until data saturation was achieved. Eight themes emerged from data analysis: (1) Denying versus dealing with reality: He's not coming home; (2) Navigating pregnancy: Flying solo while running on empty; (3) Planning for birth: Gathering my team; (4) My safety net: A band of sisters; (5) Unplanned journey: A bittersweet homecoming; (6) Being there: Network of family and friends; (7) Not being there: Let down by others; and (8) Re-creating home: A new normal. These themes described the emotions, vulnerability, challenges, and issues experienced by these women. Women's health care providers can serve as advocates for widows as well as teaching others about the grieving process. This study gave these women who became widowed while pregnant a voice.

Anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified have a significant impact on the health care and childbearing outcomes of the female population. Primary care contact for gynecologic care, childbearing, or infertility can serve as a critical entry point for the initial recognition of potentially devastating disorders that may result in permanent impairment and/or chronic debilitation. This review addresses the nature and prevalence of eating disorders and the management of pregnancy complicated by an active eating disorder or a history of an eating disorder. Genetic influences and intergenerational transmission of eating disorders are discussed. Finally, the increased risk for postpartum depression among women with a current or past eating disorder is examined. Factors critical to improving pregnancy outcome and reducing the risk for exacerbation or relapse in the postpartum period are identified.

Perianesthesia care provided to obstetric patients is on the rise due to current obstetric practice habits, changes in the maternal population, and the increased desire for scheduled childbirth. Both scheduled and emergent cesarean deliveries create risk, yet the use of general anesthesia increases maternal morbidity and mortality significantly. Obstetric emergencies make up the majority of emergent cesarean deliveries. Detrimental events during pregnancy and childbirth may be categorized into hemorrhagic, septic, or anaphylactic shock. Excessive loss of circulating volume with subsequent loss in oxygenation creates an environment for multisystem organ dysfunction syndrome (MODS). Both MODS and pregnancy are hyperdynamic and hypermetabolic states. Close monitoring is needed to differentiate pregnancy for the progression of organ dysfunction. Caring for pregnant women with the intent that pregnancy is a normal, physiologic state can lead to complacency and the risk of misdiagnosis. The purpose of this article is to review current obstetric emergencies that place the obstetric population at risk for MODS and offer management options to perianesthesia providers.

During the last decade, there has been a dramatic rise in the availability and use of medicinal herbal preparations. Childbearing women are among those who are asking nurses about herbal use, and therefore nurses need to learn more about this topic. One of the most important points to understand is that in the United States herbs are classified as dietary supplements (not drugs), and manufacturers are therefore not required to provide proof of efficacy or safety before selling these substances. Few studies about effects of herbs have been conducted in the general population, and fewer still have been published about pregnancy use. Because the perinatal nurse has two patients to consider when caring for a pregnant woman, he or she has two equally important mandates: to help the mother without harming the fetus. This article provides an overview of key concepts underlying herbal use in general and also safety in pregnancy. Common herbs that can be safely be used in pregnancy are presented in detail to enable the nurse to better care for the pregnant woman who is considering herbal use.

The purpose of this article is to help nurses understand how to quickly and effectively manage the nursing care of patients with perinatal hemorrhage. The etiology, symptoms, medical management, and nursing care of the patient experiencing a perinatal hemorrhage are discussed. Hemorrhage during the antepartum, intrapartum, or postpartum period is a life-threatening emergency for the mother and/or fetus. Early antepartum hemorrhage (before 20 weeks gestation) can be related to abortion/miscarriage, ectopic pregnancy, or gestational trophoblastic disease; late antepartum hemorrhage (after 20 weeks gestation) may result from placental abruption and placenta previa. Intrapartum hemorrhage is most commonly due to placental abruption, or to uterine rupture, uterine inversion, invasive conditions of the placenta, or complications of Cesarean birth. Postpartum hemorrhage is defined as blood loss greater than 500 ml in a vaginal delivery or 1000 ml in a Cesarean birth; early postpartum hemorrhage occurs during the first 24 hours after delivery; late postpartum hemorrhage occurs after the first 24 hours after delivery. The most common cause of postpartum hemorrhage is uterine atony; however, lacerations, hematomas, and subinvolution of the uterus can also cause postpartum hemorrhage. Nurses who understand how to assess, plan, intervene, and evaluate outcomes for perinatal hemorrhage are in the position to prevent the major tragedies that can accompany hemorrhage in pregnancy and shortly afterward.

Every locale in the United States is covered by a public health entity, generally known as the local health department, which is an arm of local, state, and federal governments, and is designed to protect, promote, and preserve the health of the population. To meet these responsibilities, health departments often become providers of personal health-care services, including prenatal care. The common assumption that these publicly funded prenatal services are in some way inferior to privately secured care is unfounded. Not only do local health department clinics provide quality care, they also extend the care to address social, nutritional, and psychologic risks; these non-medical interventions are likely to benefit those at greatest risk for prematurity and other poor pregnancy outcomes. Current budget constraints in many locales are putting these services at risk; it is essential that nurses understand the importance of advocating for the continuation of women's healthcare services in local health departments.

Objective: To determine whether teenagers partnered with adult men were more likely to report domestic violence and trauma-related care during pregnancy than teenagers partnered with male peers., Design: Nonexperimental, descriptive comparative design., Setting: Postpartum unit in a large, urban teaching hospital., Participants: English-speaking teenagers who recently delivered a live infant., Methods: Semistructured interviews lasting from 30 minutes to 2 hours., Instruments: The Abuse Assessment Screen, the Danger Assessment Scale., Main Outcome Measures: Domestic violence and trauma-related care during pregnancy., Results: Teenagers with adult partners were not more likely to report domestic violence or seek trauma-related care during pregnancy than teenagers with peer-age partners., Conclusion: Researchers, policy makers, and health care providers should continue to address violence occurring among pregnant teenagers by identifying subgroups who may be at increased risk of abuse.

New findings and diagnostic advances warrant revisiting key features of acute non-obstetric abdominal pain in pregnancy. Four of the most frequently seen conditions warranting surgical intervention are: appendicitis, cholecystitis, pancreatitis, and bowel obstruction. Because pregnancy often masks abdominal complaints, effectively assessing and triaging abdominal pain in pregnant women can be difficult. Working in obstetric triage settings and triaging obstetric phone calls demand continual updating of abdominal assessment knowledge and clinical skills.

Lead poisoning remains a significant problem in the United States affecting the health of women and children. Although the damage is greatest at higher levels of accumulation, no level of lead has been found to be safe. Over the last 25 years, the blood level of lead thought to be associated with toxicity has dropped dramatically, from to 60 mcg/dL in 1960 to 10 mcg/dL today. Studies confirm that exposure to lead causes kidney damage, encephalopathy, and impaired cognitive function in children and in adults. Recent evidence indicates children with levels less than 10 mcg/dL may suffer from compromised development and intellectual performance later in life. This article discusses the case of a woman found to have lead poisoning during pregnancy. Environmental sources of lead, implications for the immediate and future health of the fetus and mother, and techniques clinicians can use in their practice to minimize the adverse effect of lead on their clients are reviewed.

Purpose: To determine the impact of asthma during pregnancy from the perspective of the pregnant woman., Study Design and Methods: A descriptive survey using the Internet for subject recruitment and data collection was conducted using an adaptation of the Cancer Survivors Survey Questionnaire. Women with asthma who were pregnant or who had recently given birth (n = 166) were the sample. Women responded from the United States, Canada, Europe, and Asia. Physical symptoms, emotional responses, and coping strategies to deal with the asthma were queried., Results: Women reported a variety of respiratory difficulties including wheezing, coughing, and shortness of breath. They were concerned about avoiding triggers leading to acute asthma, the effect of the asthma medications on the fetus, and losing their jobs due to absenteeism. They wanted to know more about how to prevent an asthma attack and what effect their disease could have on their unborn infants., Clinical Implications: Women need education and support to help them deal with asthma during pregnancy. Nursing can have an important role in teaching these women and helping them monitor their asthma status during pregnancy.

Partner violence is a long-term health risk factor that can potentially have far-reaching, negative consequences on both those abused and their loved ones. The term "partner" is used to define opposite and same sex couples who are in relationships on a continuum ranging from casually dating to marriage. Partner violence includes physical, sexual, psychological, and economic abuse, as well as stalking behaviors. Even though the American Medical Association recommends screening for partner violence at multiple levels, there are many shortcomings of the current screening and intervention practice. Several factors facilitating the ineffectiveness of current practice include a lack of information related to the prevalence, duration, and severity of partner violence; physician s misguided beliefs regarding a victim s desire to disclose; and barriers that the victim faces when deciding whether to disclose partner violence. This article addresses these shortcomings and identifies nurses as an invaluable resource that has been under-utilized for screening and responding to partner violence. Also highlighted is one technique know by the acronym "RADAR" that is designed to address issues of both screening and intervention. Finally, resources for both health care practitioners and victims of abuse are provided.

Intimate partner violence is responsible for 30% of female homicides in the U. S. and has multiple negative health consequences. It is identified as one of the objectives in Healthy People 2010. Women are more likely to be assaulted by a current or former intimate partner than an acquaintance, family member, friend, or stranger. Universal screening is advocated as an effective approach in identifying affected women. There exists a few states mandating report of women with injuries resulting from IPV but it is only clearly mandated in California. Interventions to address the problem include those focused on increasing identification and screening, and treatment of intimate partner violence. This paper reviews the epidemiology, identification and screening, and interventions for IPV. The role for nursing is discussed concluding with directions for further investigation.

This article presents a review of the literature on the obstetric, medical, and neonatal health risks as well as psychosocial outcomes associated with early childbearing. An important concern in adolescent pregnancies is the increased risk for infant morbidity and mortality as a result of higher incidence of preterm births and low-birthweight infants. Implications for prenatal and postpartum nursing care are discussed. Promising new models to improve care of young mothers and their children, such as home visitation by public health nurses, are presented and features of successful intervention programs outlined.

Telephone triage is the process by which a health care provider communicates with a client via the telephone and, thereby, assesses the presenting concerns, develops a working diagnosis, and determines a suitable plan of management. Determination of the seriousness of the situation will dictate whether a client can be cared for at a distance or whether a more comprehensive in-person evaluation is in order. The process of telephone triage is fraught with potential problems, including difficulty in establishing a reliable database, environmental distractions, cost concerns, liability issues, and, frequently, inadequate documentation. This article will describe an approach to these concerns by discussing the use of appropriate communication techniques, the development of a working diagnosis, the establishment of a plan of intervention, and the appropriate documentation of care. Such steps will go far toward diminishing the growing legal threats that arise to midwives who utilize this technology to render care to their patients.

Obstetric triage services are rapidly advancing, and the concept is becoming a popular practice pattern. As more pregnant women are evaluated in ambulatory settings, especially in high volume obstetric tertiary centers, it is now realized more and more that labor and other complaints cannot be addressed solely in labor and delivery units, nor are most of these complaints solely labor related. This article presents the results of a national survey designed to discover what contributions nurse-midwives are making to obstetric triage services. In addition, the results provide initial benchmark data on obstetric triage components against which other midwifery services can address practice issues.

Recent studies suggest that few maternity care providers are offering the assistance that women need to reduce or stop smoking during pregnancy. This is probably because of a lack of conviction among providers that they can be effective, a perception that they lack counseling skills, and the absence of reimbursement for counseling and self-help materials. Midwives have strong counseling skills and materials will soon be available that can help them and others become trained smoking counselors. Thus, midwives can easily adopt the techniques that have been shown effective in reducing or stopping smoking during pregnancy. These are a 5- to 10-minute counseling session at the first prenatal visit by a trained provider plus appropriate print materials (pregnancy-specific and culturally- and reading-level-appropriate). Guiding the smoker to select a date for quitting and checking on smoking status at each visit increase the likelihood of behavior change. These techniques should increase the quit rate, over spontaneous quitting, by 10%-20%. Managed care organizations looking for ways to reduce costly hospitalizations for low birth weight infants or ambulatory care visits for smoking-related illnesses in infants and children should support this intervention. Medicaid and tobacco settlement funds are potential sources of reimbursement for counseling and educational materials.

Most women with spinal cord injuries (SCI) resume normal reproductive function, can have sexual relationships, and become pregnant. Pregnancy is not contraindicated in women with SCI, but pregnant women with acute or chronic SCI pose unique challenges for perinatal health care providers. The normal physiologic changes of pregnancy may predispose women with SCI to potentially life-threatening complications, including autonomic hyperreflexia, pyelonephritis, respiratory insufficiency, thrombophlebitis, and unattended delivery of the infant. This article reviews the effect of SCI on female reproduction, pregnancy, and labor, and summarizes the treatment of the pregnant woman with a spinal cord injury.

Homelessness continues to increase in the United States. Families comprise the fastest growing segment of the homeless population, and estimates suggest that women head 90% of homeless families. Pregnant homeless women are exposed to more cumulative violence than are comparable low-income, housed women. Intervention strategies that may improve health care provided to pregnant homeless women include abuse and safety assessment protocols and the use of a hand-carried health record. These interventions are directed at efforts to preserve the woman's autonomy and confidentiality, reduce areas of client-provider conflict, and generally improve encounters between the client and the health care system.

The hepatitis B virus (HBV) is the most prevalent chronic infectious disease in the world, and should be better understood by nurses caring for families. Perinatal acquisition is the major cause of infection in infants and children. Without vaccine during infancy, 90% of infants born to women positive for the virus will go on to become lifelong carriers. There are significant sequelae associated with HBV infection, ranging from fulminant HBV to chronic liver disease to an increased risk for carcinoma. A comprehensive prevention and treatment strategy has been developed by the Centers for Disease Control and Prevention, which includes screening of all pregnant women for the presence of HBV, the administration of hepatitis B immunoglobulin (HBIG) at birth, and the administration of hepatitis B vaccine at birth, at 1 month of age, and at 6 months of age. Nurses working in the perinatal and pediatric specialties must understand the implications of HBV to help prevent transmission and to assist in the coordination of care and advocacy for affected populations. The community health implications for the care of women and children with HBV are clear, giving nurses the opportunity to develop a closer linkage between hospital- and community-based nursing practice.

Objective: To determine the reliability and validity of the Constipation Assessment Scale (CAS) during pregnancy., Design: Survey., Setting: The assessment tool was administered first to a group of healthy women of childbearing age in a school of nursing and then to pregnant women in their physicians' offices., Participants: A nonrandom sample of 16 nonpregnant women of childbearing age and 30 women pregnant 28 weeks or longer, 15 of whom had low-risk pregnancies and 15 of whom had high-risk pregnancies., Main Outcome Measures: The test-retest reliability, content validity, and internal consistency of the CAS were determined., Results: An expert panel review found a calculated percentage of agreement for content validity of .75 and a Cohen's kappa of .714. Test-retest reliability based on 16 nursing students yielded high positive correlations ranging from rH = .84 to rH = .92. Internal consistency of the CAS for pregnancy based on the 30 surveys indicated an alpha coefficient of .82., Conclusions: The CAS for pregnancy was found to be reliable and valid within the context of this study. Future studies designed to identify potential therapeutic interventions for constipation during pregnancy could use the CAS for pregnancy as a measurement instrument.

The New Mexico Families FIRST project seeks to reduce maternal and infant morbidity and mortality through a nursing case management approach. The responsibilities of this community nurse include outreach, education, and care coordination of Medicaid-eligible high-risk pregnant women and their children. The standards of care for these families are derived from a screening tool that identifies medical, demographic, environmental, and psychosocial risks. Although evaluation of the nurse role and the tools used to identify and care for these women and children has not been completed, sharing the developmental stages of the process should facilitate similar endeavors.

Battering during pregnancy affects the health of both pregnant women and their unborn children. The purpose of this retrospective study of 488 primarily Medicaid-eligible postpartum women was to identify the constellation of factors associated with violence. The prevalence of battering during pregnancy was 7%, similar to that found in other studies. Significant correlates of battering included anxiety, depression, housing problems, inadequate prenatal care, and drug and alcohol use. Woman battering by a partner during pregnancy was associated with a greater severity of this constellation of patterns than those experiencing abuse before pregnancy only, or those experiencing physical attack by someone other than their partner. These factors are important to recognize in nursing assessment of pregnant women.

Prenatal screening for illegal drugs poses very complex ethical problems for the nurse-midwife who must make the decision whether to screen for illegal drugs and whether to report positive results to state child abuse investigators. We argue that the results of prenatal screening for illegal drug use should not be used for determination of child abuse and that the nurse-midwife should not be required to report the results of these screens for illegal drugs to state child protection agencies. It is far from clear that required reporting offers any benefit to the fetus or future child, and there are serious ramifications of reporting for the fetus, the pregnant woman, and the nurse-midwifery profession. However, we do argue that prenatal screening for both illegal and legal drug use should be encouraged and should be done as early as possible in the pregnancy. Prenatal screening for drugs should only be used by the nurse-midwife as a diagnostic procedure wherein standard informed consent and confidentiality restraints are maintained.

The ability of the legal system to respond to the challenges of HIV positivity and AIDS has been somewhat limited. Nevertheless, there have been state and federal initiatives which have affected nurse-midwifery practice to a degree unrecognized by many in practice. Areas of particular relevance to practice have been identified and discussed in a practical way.