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Alternative Management of Shoulder Dystocia Reduces Brachial Plexus Injuries
RESEARCH
Lucas, V. A. and Sumersille, M.
Proceedings of the 2011 AWHONN Convention
Keywords dystocia Cesarean nulliparous body mass index
Childbearing
The data source was the institutional database for all women who deliver at our University Hospital. Results For the 3,802 nulliparous women, there were 935 Cesarean deliveries (24.6%), of which 222 occurred before labor (5.8% overall). Of 3,580 nulliparas who labored, 713 (19.9%) experienced Cesarean. To study the relationship between BMI and dystocia during labor, the dataset was limited to those cases with data to compute prepregnancy BMI and total gestational weight gain leaving a sample of 3,347 nulliparas. These women had a mean age of 23.9 (16) years; were predominantly single (51%); and racially distributed as 40% non-Hispanic White, 38.4% Hispanic, 14.5% Black, 4.2% Asian, and 2.9% other. The overall Cesarean rate was 20.3%. A signi¢cantly increased rate of Cesarean delivery from 15% to 35.2% (w2 5 61.8, 5 df, po.001) occurred as BMI category increased from underweight to obese III (BMI440). There was no relationship between pregnancy weight gain and the incidence of Cesarean.
Overall, the Cesarean indication was dystocia (66.8%), nonreassuring fetal heart tracing (30.6%), and other (2.6%). The incidence of Cesarean for dystocia increased signi¢cantly from 10.9% among underweight/normal weight to 22.2% among obese nulliparous women (w2 5 45.7, 2 df, po.001). Signi¢cant logistic regression predictors of Cesarean were induction of labor; racial/ethnic minority designation; maternal age; and overweight or obese BMI. Conclusion/Implications for Nursing Practice The slightly lower rate of Cesarean in this nulliparous population compared with the national rate of 26% (2006) is likely due to an emphasis on evidence-based care, a state with the nation’s lowest rates of obesity, and multidisciplinary providers with nurse-midwives attending approximately 40% of all births. E¡orts to reduce women’s prepregnancy BMI are indicated as one strategy to decrease the rate of primary Cesarean delivery. In vitro evidence suggests the need for research into biological links between adiposity and uterine function.
Alternative Management of Shoulder Dystocia Reduces Brachial Plexus Injuries Paper Presentation Vicki A. Lucas, RNC, BSN, MNEd, WHNP, PhD, PeriGen Inc. and Vicki Lucas, LLC, Phoenix, MD
Melanie Sumersille, CNM, MSN, Department of OB/
Objective o examine di¡erences in brachial plexus injury (BPI) with traditional and alternative management of shoulder dystocia (SD).
T
Design Retrospective review of birth records pre- and postintervention.
GYN, MediSys Health Network, Jamaica, NY
Keywords shoulder dystocia brachial plexus injury alternative nursing management clinical simulations
Childbearing
Setting An urban hospital located in a large multicultural city located in the north eastern United States. Patients/Participants The pre-intervention group was 5,334 birth records from 2004 to 2006. The postintervention group was 4,517 birth records from 2007 to 2009. Methods Data were collected during a chart review of 16,124 birth records. Only birth records from live, singleton, cephalic infants 436 weeks gestation and 42,500 g were included in the study. The traditional
JOGNN 2011; Vol. 40, Supplement 1
management was that recommended for SD by the American College of Obstetricians and Gynecologists (ACOG), including the McRoberts maneuver as the ¢rst or second maneuver. The alternative management was stop pushing, remove hands from baby’s head, rotation into an oblique plane with suprapubic pressure, change mother’s position to other than McRoberts, use Wood’s maneuver and attempt delivery of posterior shoulder. The variables examined between the groups were McRoberts maneuver, shoulder/arm weakness in delivery room, minutes to SD resolution, BPI severity, apgar at 5 minutes, cord PH, cord base excess, neonatal disposition, episiotomy, birth weight, type of delivery, and maternal body mass index (BMI). Results Two-sided T test and Kolmogorov-Smirnov (KS) revealed the following: signi¢cant di¡erences (p 5 o.05) in the postintervention group, fewer McRoberts, fewer BPI, fewer transient weakness, fewer episiotomies, longer time for SD resolution, higher Cesarean rate, lower birth weight, and lower BMI. All other variables were not signi¢cantly di¡erent between the groups.
S95
RESEARCH Proceedings of the 2011 AWHONN Convention
Conclusion/Implications for Nursing Practice Alternative management of SD appears to result in fewer BPI and better neonatal outcomes than traditional management. More research is necessary to further re¢ne the alternative management strategy and duplication of the results in other clinical set-
tings. There is evidence for need for strong nursing leadership in the management of SD and for the development of training simulations for the entire health care team in the management of SD and other obstetric emergencies.
Exploring the Relationship Between Mental Illness and Preeclampsia Paper Presentation Objective o investigate the following: Hypothesis 1: there is a statistically signi¢cant positive relationship between mental illness and preeclampsia. Hypothesis 2: women with a mental illness are at increased odds to develop preeclampsia during pregnancy. Hypothesis 3: women with a mental illness are at increased odds to develop preeclampsia during pregnancy when controlling for confounding variables.
T
Design Secondary data analysis of a large data set collected at an urban medical center to gather information for a study examining the relationship between mental illness and preeclampsia. Setting A Baltimore hospital. Patients/Participants The sample included all delivery hospital admissions between January 1, 2006 and December 31, 2006. Methods Data were originally collected on 2,678 patients. After the application of speci¢c inclusion and exclusion criteria, the ¢nal sample size for this study was N 5 2,629. Using Statistical Package for the Social Sciences, analysis was run on the applicable variables to determine if any statistical signi¢cance existed between the variables of mental illness and preeclampsia in a three step process.
S96
Results The ¢rst hypothesis of this study was that there is a relationship between psychiatric illness and preeclampsia. The results of this study show 12.1% of women with documented mental illness had preeclampsia versus 3.9% of women without mental illness. A statistically signi¢cant relationship of mental illness with preeclampsia existed in the sample. The second hypothesis of this study was that there is a di¡erence in the odds of preeclampsia in women with a mental illness compared with women without mental illness. Within this study, women with documented mental illness had signi¢cantly greater odds of preeclampsia compared with women without documented mental illness.
Jodi M. Protokowicz, RN, PhD, Community College of Baltimore County, Bel Air, MD
Keywords mental illness pre-eclampsia secondary data analysis
Childbearing
The third hypothesis of this study was that there is a di¡erence in the odds of preeclampsia in women with a mental illness compared with women without mental illness when controlling for confounding variables. Controlling for gravidity, women with mental illness retained signi¢cantly greater odds of preeclampsia compared with women without mental illness. Women with mental illness, controlling for gravidity, had nearly 3.5 times the odds of preeclampsia. Conclusion/Implications for Nursing Practice Having a mental illness increases a woman’s odds of developing preeclampsia during pregnancy. Accurate screening for mental illness should occur during the preconception or prenatal periods to identify women at risk. Additional research is needed to further explore the relationship between mental illness and preeclampsia.
JOGNN, 40, S85-S119; 2011. DOI: 10.1111/j.1552-6909.2011.01243.x
http://jognn.awhonn.org
Lucas, V. A. and Sumersille, M.
Proceedings of the 2011 AWHONN Convention
Keywords dystocia Cesarean nulliparous body mass index
Childbearing
The data source was the institutional database for all women who deliver at our University Hospital. Results For the 3,802 nulliparous women, there were 935 Cesarean deliveries (24.6%), of which 222 occurred before labor (5.8% overall). Of 3,580 nulliparas who labored, 713 (19.9%) experienced Cesarean. To study the relationship between BMI and dystocia during labor, the dataset was limited to those cases with data to compute prepregnancy BMI and total gestational weight gain leaving a sample of 3,347 nulliparas. These women had a mean age of 23.9 (16) years; were predominantly single (51%); and racially distributed as 40% non-Hispanic White, 38.4% Hispanic, 14.5% Black, 4.2% Asian, and 2.9% other. The overall Cesarean rate was 20.3%. A signi¢cantly increased rate of Cesarean delivery from 15% to 35.2% (w2 5 61.8, 5 df, po.001) occurred as BMI category increased from underweight to obese III (BMI440). There was no relationship between pregnancy weight gain and the incidence of Cesarean.
Overall, the Cesarean indication was dystocia (66.8%), nonreassuring fetal heart tracing (30.6%), and other (2.6%). The incidence of Cesarean for dystocia increased signi¢cantly from 10.9% among underweight/normal weight to 22.2% among obese nulliparous women (w2 5 45.7, 2 df, po.001). Signi¢cant logistic regression predictors of Cesarean were induction of labor; racial/ethnic minority designation; maternal age; and overweight or obese BMI. Conclusion/Implications for Nursing Practice The slightly lower rate of Cesarean in this nulliparous population compared with the national rate of 26% (2006) is likely due to an emphasis on evidence-based care, a state with the nation’s lowest rates of obesity, and multidisciplinary providers with nurse-midwives attending approximately 40% of all births. E¡orts to reduce women’s prepregnancy BMI are indicated as one strategy to decrease the rate of primary Cesarean delivery. In vitro evidence suggests the need for research into biological links between adiposity and uterine function.
Alternative Management of Shoulder Dystocia Reduces Brachial Plexus Injuries Paper Presentation Vicki A. Lucas, RNC, BSN, MNEd, WHNP, PhD, PeriGen Inc. and Vicki Lucas, LLC, Phoenix, MD
Melanie Sumersille, CNM, MSN, Department of OB/
Objective o examine di¡erences in brachial plexus injury (BPI) with traditional and alternative management of shoulder dystocia (SD).
T
Design Retrospective review of birth records pre- and postintervention.
GYN, MediSys Health Network, Jamaica, NY
Keywords shoulder dystocia brachial plexus injury alternative nursing management clinical simulations
Childbearing
Setting An urban hospital located in a large multicultural city located in the north eastern United States. Patients/Participants The pre-intervention group was 5,334 birth records from 2004 to 2006. The postintervention group was 4,517 birth records from 2007 to 2009. Methods Data were collected during a chart review of 16,124 birth records. Only birth records from live, singleton, cephalic infants 436 weeks gestation and 42,500 g were included in the study. The traditional
JOGNN 2011; Vol. 40, Supplement 1
management was that recommended for SD by the American College of Obstetricians and Gynecologists (ACOG), including the McRoberts maneuver as the ¢rst or second maneuver. The alternative management was stop pushing, remove hands from baby’s head, rotation into an oblique plane with suprapubic pressure, change mother’s position to other than McRoberts, use Wood’s maneuver and attempt delivery of posterior shoulder. The variables examined between the groups were McRoberts maneuver, shoulder/arm weakness in delivery room, minutes to SD resolution, BPI severity, apgar at 5 minutes, cord PH, cord base excess, neonatal disposition, episiotomy, birth weight, type of delivery, and maternal body mass index (BMI). Results Two-sided T test and Kolmogorov-Smirnov (KS) revealed the following: signi¢cant di¡erences (p 5 o.05) in the postintervention group, fewer McRoberts, fewer BPI, fewer transient weakness, fewer episiotomies, longer time for SD resolution, higher Cesarean rate, lower birth weight, and lower BMI. All other variables were not signi¢cantly di¡erent between the groups.
S95
RESEARCH Proceedings of the 2011 AWHONN Convention
Conclusion/Implications for Nursing Practice Alternative management of SD appears to result in fewer BPI and better neonatal outcomes than traditional management. More research is necessary to further re¢ne the alternative management strategy and duplication of the results in other clinical set-
tings. There is evidence for need for strong nursing leadership in the management of SD and for the development of training simulations for the entire health care team in the management of SD and other obstetric emergencies.
Exploring the Relationship Between Mental Illness and Preeclampsia Paper Presentation Objective o investigate the following: Hypothesis 1: there is a statistically signi¢cant positive relationship between mental illness and preeclampsia. Hypothesis 2: women with a mental illness are at increased odds to develop preeclampsia during pregnancy. Hypothesis 3: women with a mental illness are at increased odds to develop preeclampsia during pregnancy when controlling for confounding variables.
T
Design Secondary data analysis of a large data set collected at an urban medical center to gather information for a study examining the relationship between mental illness and preeclampsia. Setting A Baltimore hospital. Patients/Participants The sample included all delivery hospital admissions between January 1, 2006 and December 31, 2006. Methods Data were originally collected on 2,678 patients. After the application of speci¢c inclusion and exclusion criteria, the ¢nal sample size for this study was N 5 2,629. Using Statistical Package for the Social Sciences, analysis was run on the applicable variables to determine if any statistical signi¢cance existed between the variables of mental illness and preeclampsia in a three step process.
S96
Results The ¢rst hypothesis of this study was that there is a relationship between psychiatric illness and preeclampsia. The results of this study show 12.1% of women with documented mental illness had preeclampsia versus 3.9% of women without mental illness. A statistically signi¢cant relationship of mental illness with preeclampsia existed in the sample. The second hypothesis of this study was that there is a di¡erence in the odds of preeclampsia in women with a mental illness compared with women without mental illness. Within this study, women with documented mental illness had signi¢cantly greater odds of preeclampsia compared with women without documented mental illness.
Jodi M. Protokowicz, RN, PhD, Community College of Baltimore County, Bel Air, MD
Keywords mental illness pre-eclampsia secondary data analysis
Childbearing
The third hypothesis of this study was that there is a di¡erence in the odds of preeclampsia in women with a mental illness compared with women without mental illness when controlling for confounding variables. Controlling for gravidity, women with mental illness retained signi¢cantly greater odds of preeclampsia compared with women without mental illness. Women with mental illness, controlling for gravidity, had nearly 3.5 times the odds of preeclampsia. Conclusion/Implications for Nursing Practice Having a mental illness increases a woman’s odds of developing preeclampsia during pregnancy. Accurate screening for mental illness should occur during the preconception or prenatal periods to identify women at risk. Additional research is needed to further explore the relationship between mental illness and preeclampsia.
JOGNN, 40, S85-S119; 2011. DOI: 10.1111/j.1552-6909.2011.01243.x
http://jognn.awhonn.org