Maternal and neonatal outcomes by labor onset type and gestational age.

OBJECTIVE: We sought to determine maternal and neonatal outcomes by labor onset type and gestational age. STUDY DESIGN: We used electronic medical records data from 10 US institutions in the Consortium on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age. RESULTS: Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks (P < .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.28-0.53), sepsis (OR, 0.36; 95% CI, 0.26-0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48-0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08-9.54) with elective induction, 1.16 (95% CI, 0.24-5.58) with indicated induction, and 6.57 (95% CI, 1.78-24.30) with cesarean without labor compared to spontaneous labor. CONCLUSION: Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk.

Certified nurse midwives effects on catecholamine levels and maternal anxiety during labor

Studies of nurse midwifery care in the last twenty one years have reported excellent birth outcomes (Levy, Wilkenson and Marine, 1971; Platt et al. 1985; Stone et al. 1976). These outcomes are frequently attributed to the special support offered during labor and delivery by nurse midwives. This supportive style is thought to decrease catecholamine levels by reducing maternal anxiety. This prospective observational study evaluated catecholamine levels, anxiety levels, in-hospital costs, obstetrical practices and outcomes between low risk, term, labor and delivery primigravida patients managed by obstetrical residents (n = 55) or by certified nurse-midwives CNM (n = 59). The two groups were similar with regard to obstetrical risk factors present at admission. Each group was selected over the same period of time between March 23, 1994 and November 2, 1994. Specific catecholamines evaluated were epinephrine and norepinephrine. Obstetrical and newborn characteristics were also compared. This study did not prove that there is a decreased level in stress as indicated by lower levels of epinephrine and norepinephrine in nurse-midwife patients compared to obstetrical resident patients after adjusting for the use of epidural anesthesia. There was also no difference found in the perceived anxiety levels between the two groups. This study did confirm that nurse-midwives and obstetrical residents have different practice styles. Nurse-midwife patients had fewer augmented deliveries, fewer operative deliveries, less blood loss, fewer episiotomies and fewer third and fourth degree lacerations. The physician's choice to utilize more interventions such as continuous fetal monitoring and epidural anesthesia did not improve outcomes. The hospital cost of the nurse-midwife patients in this study was 35 percent lower than the physician patients. ^

Comparison of Bispectral Index (BIS) and Patient State Index (PSI) as objective measures of sedation and analgesia in critically ill/injured patients

Critically ill and injured patients require pain relief and sedation to reduce the body's stress response and to facilitate painful diagnostic and therapeutic procedures. Presently, the level of sedation and analgesia is guided by the use of clinical scores which can be unreliable. There is therefore, a need for an objective measure of sedation and analgesia. The Bispectral Index (BIS) and Patient State Index (PSI) were recently introduced into clinical practice as objective measures of the depth of analgesia and sedation. ^ Aim. To compare the different measures of sedation and analgesia (BIS and PSI) to the standard and commonly used modified Ramsay Score (MRS) and determine if the monitors can be used interchangeably. ^ Methods. MRS, BIS and PSI values were obtained in 50 postoperative cardiac surgery patients requiring analgesia and sedation from June to December 2004. The MRS, BIS and PSI values were assessed hourly for up to 6-h by a single observer. ^ The relationship between BIS and PSI values were explored using scatter plots and correlation between MRS, BIS and PSI was determined using Spearman's correlation coefficient. Intra-class correlation (ICC) was used to determine the inter-rater reliability of MRS, BIS and PSI. Kappa statistics was used to further evaluate the agreement between BIS and PSI at light, moderate and deep levels of sedation. ^ Results. There was a positive correlation between BIS and PSI values (Rho = 0.731, p<0.001). Intra-class correlation between BIS and PSI was 0.58, MRS and BIS 0.43 and MRS and PSI 0.27. Using Kappa statistics, agreement between MRS and BIS was 0.35 (95% CI: 0.27–0.43) and for MRS and PSI was 0.21 (95% CI: 0.15–0.28). The kappa statistic for BIS and PSI was 0.45 (95% CI: 0.37–0.52). Receiver operating characteristics (ROC) curves constructed to detect undersedation indicated an area under the curve (AUC) of 0.91 (95% CI = 0.87 to 0.94) for the BIS and 0.84 (95% CI = 0.79 to 0.88) for the PSI. For detection of oversedation, AUC for the BIS was 0.89 (95% CI = 0.84 to 0.92) and 0.80 (95% CI = 0.75 to 0.85) for the PSI. ^ Conclusions. There is a statistically significant positive correlation between the BIS and PSI but poor correlation and poor test agreement between the MRS and BIS as well as MRS and PSI. Both the BIS and PSI demonstrated a high level of prediction for undersedation and oversedation; however, the BIS and PSI can not be considered interchangeable monitors of sedation. ^

Why does low dose morphine augment fentanyl analgesia?

Opioids dominate the field of pain management because of their ability to provide analgesia in many medical circumstances. However, side effects including respiratory depression, constipation, tolerance, physical dependence, and the risk of addiction limit their clinical utility. Fear of these side effects results in the under-treatment of acute pain. For many years, research has focused on ways to improve the therapeutic index (the ratio of desirable analgesic effects to undesirable side effects) of opioids. One strategy, combining opioid agonists that bind to different opioid receptor types, may prove successful.^ We discovered that subcutaneous co-administration of a moderately analgesic dose of the mu-opioid receptor (MOR) selective agonist fentanyl (20μg/kg) with subanalgesic doses of the less MOR-specific agonist morphine (100ng/kg-100μg/kg), augmented acute fentanyl analgesia in rats. Parallel [35S]GTPγS binding studies using naïve rat substantia gelatinosa membrane treated with fentanyl (4μM) and morphine (1nM-1pM) demonstrated a 2-fold increase in total G-protein activation. This correlation between morphine-induced augmentation of fentanyl analgesia and G-protein activation led to our proposal that interactions between MORs and DORs underlie opioid-induced augmentation. We discovered that morphine-induced augmentation of fentanyl analgesia and G-protein activity was mediated by DORs. Adding the DOR-selective antagonist naltrindole (200ng/kg, 40nM) at doses that did not alter the analgesic or G-protein activation of fentanyl, blocked increases in analgesia and G-protein activation induced by fentanyl/morphine combinations. Equivalent doses of the MOR-selective antagonist cyprodime (20ng/kg, 4nM) did not block augmentation. Substitution of the DOR-selective agonist SNC80 for morphine yielded similar results, further supporting our conclusion that interactions between MORs and DORs are responsible for morphine-induced augmentation of fentanyl analgesia and G-protein activation. Confocal microscopy of rat substantia gelatinosa showed that changes in the rate of opioid receptor internalization did not account for these effects.^ In conclusion, fentanyl analgesia augmentation by subanalgesic morphine is mediated by increased G-protein activation resulting from functional interactions between MORs and DORs, not changes in MOR internalization. Additional animal and clinical studies are needed to determine whether side effect incidence changes following opioid co-administration. If side effect incidence decreases or remains unchanged, these findings could have important implications for clinical pain treatment. ^

A comparison of labor and delivery management activities in two settings

Similarities and differences in management activities and patient health outcomes between a traditional physician staffed labor and delivery setting and a certified nurse-midwife staffed Birth Center within the same hospital were described. The 950 study subjects, low income, minority women, were classified as low obstetrical risk by a POPRAS score of 25 points or less at time of admission for labor and delivery. The study subjects were similar in demographic, antepartum and intrapartum characteristics; the labor course was problem free for the majority in both settings. There were no remarkable differences in health outcomes between the groups. Management activities varied between settings; these variations were policy related rather than health related. The POPRAS rating system was an accurate predictor for 93% of BC subjects and 85% of LDU subjects. Charge for service was approximately $600 less for BC women; length of stay did not contribute to the difference in charge. Overall, BC respondents to the attitude survey were more satisfied with their labor and delivery experience than L\&DU women. ^

A case-control study to identify risk factors for preterm labor in Colorado Springs, Colorado

The study objectives were to determine risk factors for preterm labor (PTL) in Colorado Springs, CO, with emphasis on altitude and psychosocial factors, and to develop a model that identifies women at high risk for PTL. Three hundred and thirty patients with PTL were matched to 460 control patients without PTL using insurance category as an indirect measure of social class. Data were gathered by patient interview and review of medical records. Seven risk groups were compared: (1) Altitude change and travel; (2) Psychosocial ((a) child, sexual, spouse, alcohol and drug abuse; (b) neuroses and psychoses; (c) serious accidents and injuries; (d) broken home (maternal parental separation); (e) assault (physical and sexual); and (f) stress (emotional, domestic, occupational, financial and general)); (3) demographic; (4) maternal physical condition; (5) Prenatal care; (6) Behavioral risks; and (7) Medical factors. Analysis was by logistic regression. Results demonstrated altitude change before or after conception and travel during pregnancy to be non-significant, even after adjustment for potential confounding variables. Five significant psychosocial risk factors were determined: Maternal sex abuse (p = 0.006), physical assault (p = 0.025), nervous breakdown (p = 0.011), past occupational injury (p = 0.016), and occupational stress (p = 0.028). Considering all seven risk groups in the logistic regression, we chose a logistic model with 11 risk factors. Two risk factors were psychosocial (maternal spouse abuse and past occupational injury), 1 was pertinent to maternal physical condition ($\le$130 lbs. pre-pregnancy weight), 1 to prenatal care ($\le$10 prenatal care visits), 2 pertinent to behavioral risks ($>$15 cigarettes per day and $\le$30 lbs. weight gain) and 5 medical factors (abnormal genital culture, previous PTB, primiparity, vaginal bleeding and vaginal discharge). We conclude that altitude change is not a risk factor for PTL and that selected psychosocial factors are significant risk factors for PTL. ^

OUT-OF-HOSPITAL CHILDBEARING CENTERS IN THE UNITED STATES: A DESCRIPTIVE STUDY OF THE DEMOGRAPHIC AND MEDICAL-OBSTETRIC CHARACTERISTICS OF WOMEN BEGINNING LABOR THEREIN 1972-1979

There is currently much interest in the appropriate use of obstetrical technology, cost containment and meeting consumers' needs for safe and satisfying maternity care. At the same time, there has been an increase in professionally unattended home births. In response, a new type of service, the out-of-hospital childbearing center (CBC) has been developed which is administratively and structurally separate from the hospital. In the CBC, maternity care is provided by certified nurse-midwives to carefully screened low risk childbearing families in conjunction with physician and hospital back-up.^ It was the purpose of this study to accomplish the following objectives: (1) To describe in a historical prospective study the demographic and medical-obstetric characteristics of patients laboring in eleven selected out-of-hospital childbearing centers in the United States from May 1, 1972, to December 15, 1979. Labor is defined as the onset of regular contractions as determined by the patient. (2) To describe any differences between those patients who require transfer to a back-up hospital and those who do not. (3) To describe administrative and service characteristics of eleven selected out-of-hospital childbearing centers in the United States. (4) To compare the demographic and medical-obstetric characteristics of women laboring in eleven selected out-of-hospital childbearing centers with a national sample of women of similar obstetric risk who according to birth certificates delivered legitimate infants in a hospital setting in the United States in 1972.^ Research concerning CBCs and supportive to the development of CBCs including studies which identified factors associated with fetal and perinatal morbidity and mortality, obstetrical risk screening, and the progress of technological development in obstetrics were reviewed. Information concerning the organization and delivery of care at each selected CBC was also collected and analyzed.^ A stratified, systematic sample of 1938 low risk women who began labor in a selected CBC were included in the study. These women were not unlike those described previously in small single center studies reported in the literature. The mean age was 25 years. Sixty-three per cent were white, 34 per cent Hispanic, 88 per cent married, 45 per cent had completed at least two years of college, nearly one-third were professionals and over a third were housewives. . . . (Author's abstract exceeds stipulated maximum length. Discontinued here with permission of school.) UMI ^

Assessing the impact of electronic health record technology adoption on hospital labor efficiency

Information technology (IT) in the hospital organization is fast becoming a key asset, particularly in light of recent reform legislation in the United States calling for expanding the role of IT in our health care system. Future payment reductions to hospitals included in current health reform are based on expected improvements in hospital operating efficiency. Since over half of hospital expenses are for labor, improved efficiency in use of labor resources can be critical in meeting this challenge. Policy makers have touted the value of IT investments to improve efficiency in response to payment reductions. ^ This study was the first to directly examine the relationship between electronic health record (EHR) technology and staffing efficiency in hospitals. As the hospital has a myriad of outputs for inpatient and outpatient care, efficiency was measured using an industry standard performance metric – full time equivalent employees per adjusted occupied bed (FTE/AOB). Three hypotheses were tested in this study.^ To operationalize EHR technology adoption, we developed three constructs to model adoption, each of which was tested by separate hypotheses. The first hypothesis that a larger number of EHR applications used by a hospital would be associated with greater staffing efficiency (or lower values of FTE/AOB) was not accepted. Association between staffing efficiency and specific EHR applications was the second hypothesis tested and accepted with some applications showing significant impacts on observed values for FTE/AOB. Finally, the hypothesis that the longer an EHR application was used in a hospital would be associated with greater labor efficiency was not accepted as the model showed few statistically significant relationships to FTE/AOB performance. Generally, there does not appear a strong relationship between EHR usage and improved labor efficiency in hospitals.^ While returns on investment from EHR usage may not come from labor efficiencies, they may be better sought using measures of quality, contribution to an efficient and effective local health care system, and improved customer satisfaction through greater patient throughput.^

Planning for Emotional Labor and Secondary Traumatic Stress in Child Welfare Organizations

This analysis provides an emergent framework that emphasizes a neglected component of both direct practice with families and organizational development. Human emotions, both beneficial (positive emotional labor) and harmful (negative emotional labor), have received short shrift in leadership development, supervision, direct practice preparation and supports, and workforce stabilization, and professionalization. Significantly, a key indicator of negative emotional labor—secondary traumatic stress (STS)—often has been ignored and neglected, despite the fact that it may be endemic in the workforce. STS typically results from traumatic events in practice, but it also stems from workplace violence. Often undetected and untreated, STS is at least a hidden correlate and perhaps a probable cause of myriad problems such as questionable practice with families, life-work conflicts, undesirable workforce turnover, and a sub-optimal organizational climate. Special interventions are needed. At the same time, new organizational designs are needed to promote and reinforce positive emotional labor. Arguably, positive emotional labor and the positive organizational climates it facilitates are requisites for harmonious relations between jobs and personal lives, desirable workforce retention, and better outcomes for children and families. What’s more, specialized interventions for positive emotional labor constitute a key component in the prevention system for STS. A dual design for positive emotional labor and STS (and other negative emotional labor) prevention/intervention is provided herewith. Early detection and rapid response systems for STS, with social work leadership, receive special attention. Guidelines for new organizational designs for emotional labor in child welfare are offered in conclusion.