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Strategies to Decrease Maternal Request for Early Elective Induction
Commentary
Photos clockwise © iStock Collection, iStock Collection, FogStock, Jose Luis Pelaez Inc / thinkstockphotos.com
Strategies to Decrease Maternal Request for Early Elective Induction BARBARA CATHERINE WALLACE
H
Historically, when third trimester discomforts became intolerable for pregnant women, the solution was to initiate childbirth as soon as the pregnancy was full-term. Until recently, the problem was in the definition what gestational age would be considered to be a term pregnancy (American College of Obstetricians and Gynecologists [ACOG], 2013a). Given the new definitions of term (Spong, 2013) and the evidence of the potential consequences of nonmedically indicated inductions and cesarean
surgical birth on both maternal and fetal health (ACOG 2013b, 2013c; Clark, Miller, et al., 2009; Eunice Kennedy Shriver National Institute on Child Health and Human Development, 2011; Hoffmire, Chess, Ben Saad, & Glantz, 2012; Tita et al., 2009), the challenge has now become how to balance a woman’s desire to “get this baby out sooner than later” with the needs of the infant to be fully developed and “ready to come out.”
Maternal Discomfort In her book, The Psychology of Women, Helene
Abstract Severe maternal discomfort in the third trimester is not a diagnostic risk justification for elective induction before 39 weeks gestation. Alternative methods of intervention and supportive resources to help sustain a woman at the end of pregnancy have been largely absent in discussions pertaining to best practices. Nurses and midwives are in an ideal position to play a leadership role in working with physician colleagues as well as other members of the health care team to broaden the conversation to include alternative and complementary interventions, and to provide guidance and assistance to help women cope with and manage the discomforts of late pregnancy. DOI: 10.1111/1751-486X.12229 Keywords elective induction | maternal discomfort | term pregnancy | third trimester
http://nwh.awhonn.org
© 2015, AWHONN
393
Providing reasons to wait for the sake of the baby, although justifiable, aren’t enough when the discomfort becomes great and the psychological focus is on separation and the drive to give birth
Barbara Catherine Wallace, EdD, MPH, MSN, CNS, is an executive nurse leader providing interim health care management services through national executive search firms. She is based in Stoughton, MA. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
394
According to Deutsch, it’s the physical and mechanical discomforts associated with the third trimester that become the driving forces in the psychological transitioning of being pregnant and seeing the fetus as an extension of the self, to parenthood, and seeing the fetus as separate and distinct from the self. Providing reasons to wait for the sake of the baby, although justifiable, aren’t enough when the discomfort becomes great and the psychological focus is on separation and the drive to give birth. From a health care management perspective, health care providers are finding themselves in a situation in which a pregnant woman is feeling miserable, helpless, sleep deprived, exhausted and angry with them. This is hardly a situation that fosters a therapeutic relationship. In some instances, out of desperation and helplessness, care providers have advised women to go to the hospital and have instructed them as what to say “to be kept” for birth. Typically, the timing coincides with the practitioners’ schedules and availability. In other instances, health care providers have reverted to loosely defining high-risk medical/obstetric indications to secure induction dates before the recommended
Nursing for Women’s Health
39 weeks, such as elevated blood pressure or decreased fetal movement. To be clear, the overriding intent of the practitioner may be prompted by a need to relieve a pregnant woman of her distress and not merely a matter of convenience or intent to deceive.
Effect on the Health Care Environment Regardless, the fallout from these behaviors and practices extend beyond the practitioner and the woman to other members of the health care team. They affect hospital secretaries booking inductions and procedures, as well as charge nurses responsible for overseeing that the inductions are appropriate, that they follow hospital policy and best practices to ensure safety and that there are adequate staff and resources available if needed. Clark, Frye, et al. (2010) reported the results of a Health Corporation of America (HCA) intervention study looking at three approaches for reduction of elective inductions at fewer than 39 weeks gestation. The three approaches included a “hard stop” approach characterized by staff
Photo © PIKSEL / thinkstockphotos.com
Commentary
Deutsch (1973), a psychoanalyst, explored the psychological transitions women experience as they transition from one trimester to the next. Her work provides some insights that may help guide practitioners as they seek to adopt a new approach to managing the severe discomforts that can be associated with the third trimester.
Volume 19
Issue 5
refusing to schedule women before 39 weeks unless the request is managed up; a “soft stop” approach leaving the practitioner responsible for compliance, coupled with peer review sessions and an “education-only” approach consisting of the provision of literature and guidelines from ACOG. In this particular study, the hardstop approach was highly statistically significant in affecting elective inductions before 39 weeks (p = .007). The soft-stop approach was also significant although considerably less so than the hard-stop (p = .025). The effect of the education-only approach did not reach statistical significance (p = .13). Given the results of this study, the hard stop approach may have its merits, but its dictatorial and authoritarian nature is not without potential consequences. This approach affects professional autonomy and respect for the clinical judgment of the practitioner. It can undermine interdisciplinary collaboration and teamwork, and can result in a culture that is adversarial and a work environment that can become unhealthy. The soft-stop approach is less controlling, but unilateral and onedimensional, involving only physicians, when the situation ultimately involves and affects the entire health care team. Even financial disincentives won’t make a difference if the source of the problem, severe maternal discomfort, isn’t addressed.
A New Approach The solution to the issue of nonmedically indicated elective inductions prior to 39 weeks may be found in a new approach that focuses on the management of late third trimester discomforts and empowers pregnant women to work with their bodies in transition. To do this, in addition to the recognition of third trimester discomforts discussed in childbirth classes, all health care providers are challenged to look outside the traditional methods of third trimester care management. This includes
October | November 2015
adding a prenatal checklist specific to third trimester discomforts for use at each visit in the third trimester. The incorporation of such a list, in conjunction with the usual medical/obstetric assessments, reinforces the significance of these discomforts and conveys to a pregnant woman an equal degree of concern and importance for their maternal well-being. A sample third trimester prenatal checklist could include some or all of the following discomforts and concerns: pain and location (ribs, back, hip, pelvis, vagina, ligaments), varicosities, pinched nerves/limb numbness and burning, heartburn, urinary fre-
encouraged. Much information can be found on blogs where pregnant women share helpful suggestions with each other. The emergence of CenteringPregnancy groups within practices can also be used as a source of support and information sharing to help with coping. Conducting focus groups could provide health care providers with additional insights into women’s third trimester needs and opportunities to help meet those needs. Last, but not least, identifying and partnering with community-based and online resources catering to helping pregnant women be more comfortable in the last trimester provide additional
This approach isn’t just about suggesting to a pregnant woman what she can do to help herself during these difficult last weeks—it’s about hardwiring needed resources into practice and providing women with concrete “lifelines” to such services
quency, swollen extremities, BraxtonHicks contractions, fatigue/insomnia, breast tenderness, thirst, nausea and vomiting, skeletal instability/fear of falling, shortness of breath, dizziness or lightheadedness, increased perspiration, weight gain, constipation, increased vaginal discharge and frightening and/or upsetting dreams. The ability of some complementary and alternative therapies and holistic approaches to address some of these discomforts needs to be recognized. Care providers could be encouraged to actively forge collaborative relationships with experts in these fields, such as exercise physiologists, pregnancy fitness coaches, massage therapists, Reiki masters, acupuncturists, chiropractors, physical and occupational therapists, mind/body experts for stress/relaxation techniques, nutritionists and others. Accessible and affordable support groups for pregnant women could be identified and participation
support. Comfort needs can include pregnancy belts/pelvic girdles, compression hosiery, shoes, support bras, comfortable work and play wear, moisture creams and sleeping pillows. Giving consideration to partnering with local pregnancy fashion experts, hair, nail and make-up artists, spas and gyms willing to offer discounts may also be helpful. Looking good, while being as comfortable as possible, translates into feeling better about oneself in the final weeks of pregnancy. This approach isn’t just about suggesting to a pregnant woman what she can do to help herself during these difficult last weeks—it’s about hardwiring needed resources into practice and providing women with concrete “lifelines” to such services.
Conclusion Given what is known about the potential maternal and fetal effects of nonmedically indicated elective induction, it’s in the best interest of women, babies
Nursing for Women’s Health
395
Washington, DC: Author. Retrieved from www.health4mom.org/zones/ go-the-full-40 Clark, S. L., Frye, D. R., Meyers, J. A. Belfort, M. A., Dilday, G. A., Koffard, S., … Perlin, J. A. (2010). Reduction in elective deliveries at < 39 weeks gestation: Comparative effectiveness of 3 approaches to change and impact on neonatal intensive care admission and stillbirth. American Journal of Obstetrics & Gynecology, 203, 449.e1–449.e6. Retrieved from dox.doi.org/10.1016/j. ajog2010.05.036
Public awareness campaigns, such as AWHONN’s “Go the Full 40” campaign are integral to helping pregnant women cope with the discomforts of pregnancy and their health care providers to help women cope with the significant discomforts they may experience toward the end of their pregnancies. A third trimester “checklist” coupled with alternative and holistic approaches to care can be included as part of best practices. Alternative and holistic interventions can transform a pregnant woman’s perception of being a helpless victim to being an empowered, active participant in her own care, and, as such, maximize her own health and well-being. Public awareness campaigns, such as AWHONN’s “Go the Full 40” campaign (AWHONN, 2015), are integral to helping pregnant women cope with the discomforts of pregnancy. The Go the Full 40 toolkit includes a calendar with day-to-day activities, many of which include self-care and comfort measures. But if a pregnant woman doesn’t have active involvement from a health care professional to motivate, support or guide her, she might not be able to incorporate these important self-care activities. Nurses and nursemidwives are in an ideal position to play a leadership role in working with
396
Nursing for Women’s Health
their physician colleagues as well as other members of the health care team to help women cope with and manage the discomforts of late pregnancy, and to help them avoid potential negative maternal and fetal health outcomes of elective inductions. NWH
References American College of Obstetricians and Gynecologists (ACOG). (2013a). Committee opinion no. 579. Definition of term pregnancy. Obstetrics & Gynecology, 122, 1139–1140. doi:10.1097/01. AOG.0000437385.88715.4a American College of Obstetricians and Gynecologists (ACOG). (2013b). Committee opinion no. 561. Nonmedically indicated early-term deliveries. Obstetrics & Gynecology, 121, 911–9115. doi:10.1097/01. AOG.0000428649.57622.a7 American College of Obstetricians and Gynecologists (ACOG). (2013c). Committee opinion no. 559. Cesarean delivery on maternal request. Obstetrics & Gynecology, 121, 904–907. doi:10.1097/01. AOG.0000428647.67925.d3.
Clark, S. L., Miller, D., Belfort, M., Dildy, G., Frye, D., & Meyers, J. (2009). Neonatal and maternal outcomes associated with elective delivery (electronic version). American Journal of Obstetrics & Gynecology, 200, 156.e1–156.e4. Retrieved from dx.doi.org/10.10161/j. ajog.2008.08068 Deutsch, H. (1973). The Psychology of Women: Volume 2—Motherhood. New York: Bantam Books, Inc. Eunice Kennedy Shriver National Institute on Child Health and Human Development. (2011). Increasing awareness of late preterm birth. Retrieved from www.nichd.nih.gov/news/ resources/spotlight/Pages/021811CME-CE-program.aspx Hoffmire, C. A., Chess, P. R. Ben Saad, T., & Glantz, J. C. (2012). Elective delivery before 39 weeks: The risk of infant admission to the neonatal intensive care unit. Maternal Child Health Journal, 16(5), 1053–1062. doi:10.1007/ s10995-011-0830-9 Spong, C. Y. (2013). Defining “term” pregnancy: Recommendations from the Defining “Term” Pregnancy Workgroup. Journal of American Medical Association, 309(23), 2445–2446. doi:10.1001/jama.2013.6235 Tita, A., Landon, M., Spong, C., Lai, Y., Levano, M. D., Varner, M. W., … Mercer, B. (2009). Timing of elective repeat cesarean delivery at term and neonatal outcomes. New England Journal of Medicine, 360(2), 111–120. doi:10.1056/ NEJMoa0803267
Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). (2015). 40 Reasons to go the full 40.
Volume 19
Issue 5
Photos clockwise © iStock Collection, iStock Collection, FogStock, Jose Luis Pelaez Inc / thinkstockphotos.com
Strategies to Decrease Maternal Request for Early Elective Induction BARBARA CATHERINE WALLACE
H
Historically, when third trimester discomforts became intolerable for pregnant women, the solution was to initiate childbirth as soon as the pregnancy was full-term. Until recently, the problem was in the definition what gestational age would be considered to be a term pregnancy (American College of Obstetricians and Gynecologists [ACOG], 2013a). Given the new definitions of term (Spong, 2013) and the evidence of the potential consequences of nonmedically indicated inductions and cesarean
surgical birth on both maternal and fetal health (ACOG 2013b, 2013c; Clark, Miller, et al., 2009; Eunice Kennedy Shriver National Institute on Child Health and Human Development, 2011; Hoffmire, Chess, Ben Saad, & Glantz, 2012; Tita et al., 2009), the challenge has now become how to balance a woman’s desire to “get this baby out sooner than later” with the needs of the infant to be fully developed and “ready to come out.”
Maternal Discomfort In her book, The Psychology of Women, Helene
Abstract Severe maternal discomfort in the third trimester is not a diagnostic risk justification for elective induction before 39 weeks gestation. Alternative methods of intervention and supportive resources to help sustain a woman at the end of pregnancy have been largely absent in discussions pertaining to best practices. Nurses and midwives are in an ideal position to play a leadership role in working with physician colleagues as well as other members of the health care team to broaden the conversation to include alternative and complementary interventions, and to provide guidance and assistance to help women cope with and manage the discomforts of late pregnancy. DOI: 10.1111/1751-486X.12229 Keywords elective induction | maternal discomfort | term pregnancy | third trimester
http://nwh.awhonn.org
© 2015, AWHONN
393
Providing reasons to wait for the sake of the baby, although justifiable, aren’t enough when the discomfort becomes great and the psychological focus is on separation and the drive to give birth
Barbara Catherine Wallace, EdD, MPH, MSN, CNS, is an executive nurse leader providing interim health care management services through national executive search firms. She is based in Stoughton, MA. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
394
According to Deutsch, it’s the physical and mechanical discomforts associated with the third trimester that become the driving forces in the psychological transitioning of being pregnant and seeing the fetus as an extension of the self, to parenthood, and seeing the fetus as separate and distinct from the self. Providing reasons to wait for the sake of the baby, although justifiable, aren’t enough when the discomfort becomes great and the psychological focus is on separation and the drive to give birth. From a health care management perspective, health care providers are finding themselves in a situation in which a pregnant woman is feeling miserable, helpless, sleep deprived, exhausted and angry with them. This is hardly a situation that fosters a therapeutic relationship. In some instances, out of desperation and helplessness, care providers have advised women to go to the hospital and have instructed them as what to say “to be kept” for birth. Typically, the timing coincides with the practitioners’ schedules and availability. In other instances, health care providers have reverted to loosely defining high-risk medical/obstetric indications to secure induction dates before the recommended
Nursing for Women’s Health
39 weeks, such as elevated blood pressure or decreased fetal movement. To be clear, the overriding intent of the practitioner may be prompted by a need to relieve a pregnant woman of her distress and not merely a matter of convenience or intent to deceive.
Effect on the Health Care Environment Regardless, the fallout from these behaviors and practices extend beyond the practitioner and the woman to other members of the health care team. They affect hospital secretaries booking inductions and procedures, as well as charge nurses responsible for overseeing that the inductions are appropriate, that they follow hospital policy and best practices to ensure safety and that there are adequate staff and resources available if needed. Clark, Frye, et al. (2010) reported the results of a Health Corporation of America (HCA) intervention study looking at three approaches for reduction of elective inductions at fewer than 39 weeks gestation. The three approaches included a “hard stop” approach characterized by staff
Photo © PIKSEL / thinkstockphotos.com
Commentary
Deutsch (1973), a psychoanalyst, explored the psychological transitions women experience as they transition from one trimester to the next. Her work provides some insights that may help guide practitioners as they seek to adopt a new approach to managing the severe discomforts that can be associated with the third trimester.
Volume 19
Issue 5
refusing to schedule women before 39 weeks unless the request is managed up; a “soft stop” approach leaving the practitioner responsible for compliance, coupled with peer review sessions and an “education-only” approach consisting of the provision of literature and guidelines from ACOG. In this particular study, the hardstop approach was highly statistically significant in affecting elective inductions before 39 weeks (p = .007). The soft-stop approach was also significant although considerably less so than the hard-stop (p = .025). The effect of the education-only approach did not reach statistical significance (p = .13). Given the results of this study, the hard stop approach may have its merits, but its dictatorial and authoritarian nature is not without potential consequences. This approach affects professional autonomy and respect for the clinical judgment of the practitioner. It can undermine interdisciplinary collaboration and teamwork, and can result in a culture that is adversarial and a work environment that can become unhealthy. The soft-stop approach is less controlling, but unilateral and onedimensional, involving only physicians, when the situation ultimately involves and affects the entire health care team. Even financial disincentives won’t make a difference if the source of the problem, severe maternal discomfort, isn’t addressed.
A New Approach The solution to the issue of nonmedically indicated elective inductions prior to 39 weeks may be found in a new approach that focuses on the management of late third trimester discomforts and empowers pregnant women to work with their bodies in transition. To do this, in addition to the recognition of third trimester discomforts discussed in childbirth classes, all health care providers are challenged to look outside the traditional methods of third trimester care management. This includes
October | November 2015
adding a prenatal checklist specific to third trimester discomforts for use at each visit in the third trimester. The incorporation of such a list, in conjunction with the usual medical/obstetric assessments, reinforces the significance of these discomforts and conveys to a pregnant woman an equal degree of concern and importance for their maternal well-being. A sample third trimester prenatal checklist could include some or all of the following discomforts and concerns: pain and location (ribs, back, hip, pelvis, vagina, ligaments), varicosities, pinched nerves/limb numbness and burning, heartburn, urinary fre-
encouraged. Much information can be found on blogs where pregnant women share helpful suggestions with each other. The emergence of CenteringPregnancy groups within practices can also be used as a source of support and information sharing to help with coping. Conducting focus groups could provide health care providers with additional insights into women’s third trimester needs and opportunities to help meet those needs. Last, but not least, identifying and partnering with community-based and online resources catering to helping pregnant women be more comfortable in the last trimester provide additional
This approach isn’t just about suggesting to a pregnant woman what she can do to help herself during these difficult last weeks—it’s about hardwiring needed resources into practice and providing women with concrete “lifelines” to such services
quency, swollen extremities, BraxtonHicks contractions, fatigue/insomnia, breast tenderness, thirst, nausea and vomiting, skeletal instability/fear of falling, shortness of breath, dizziness or lightheadedness, increased perspiration, weight gain, constipation, increased vaginal discharge and frightening and/or upsetting dreams. The ability of some complementary and alternative therapies and holistic approaches to address some of these discomforts needs to be recognized. Care providers could be encouraged to actively forge collaborative relationships with experts in these fields, such as exercise physiologists, pregnancy fitness coaches, massage therapists, Reiki masters, acupuncturists, chiropractors, physical and occupational therapists, mind/body experts for stress/relaxation techniques, nutritionists and others. Accessible and affordable support groups for pregnant women could be identified and participation
support. Comfort needs can include pregnancy belts/pelvic girdles, compression hosiery, shoes, support bras, comfortable work and play wear, moisture creams and sleeping pillows. Giving consideration to partnering with local pregnancy fashion experts, hair, nail and make-up artists, spas and gyms willing to offer discounts may also be helpful. Looking good, while being as comfortable as possible, translates into feeling better about oneself in the final weeks of pregnancy. This approach isn’t just about suggesting to a pregnant woman what she can do to help herself during these difficult last weeks—it’s about hardwiring needed resources into practice and providing women with concrete “lifelines” to such services.
Conclusion Given what is known about the potential maternal and fetal effects of nonmedically indicated elective induction, it’s in the best interest of women, babies
Nursing for Women’s Health
395
Washington, DC: Author. Retrieved from www.health4mom.org/zones/ go-the-full-40 Clark, S. L., Frye, D. R., Meyers, J. A. Belfort, M. A., Dilday, G. A., Koffard, S., … Perlin, J. A. (2010). Reduction in elective deliveries at < 39 weeks gestation: Comparative effectiveness of 3 approaches to change and impact on neonatal intensive care admission and stillbirth. American Journal of Obstetrics & Gynecology, 203, 449.e1–449.e6. Retrieved from dox.doi.org/10.1016/j. ajog2010.05.036
Public awareness campaigns, such as AWHONN’s “Go the Full 40” campaign are integral to helping pregnant women cope with the discomforts of pregnancy and their health care providers to help women cope with the significant discomforts they may experience toward the end of their pregnancies. A third trimester “checklist” coupled with alternative and holistic approaches to care can be included as part of best practices. Alternative and holistic interventions can transform a pregnant woman’s perception of being a helpless victim to being an empowered, active participant in her own care, and, as such, maximize her own health and well-being. Public awareness campaigns, such as AWHONN’s “Go the Full 40” campaign (AWHONN, 2015), are integral to helping pregnant women cope with the discomforts of pregnancy. The Go the Full 40 toolkit includes a calendar with day-to-day activities, many of which include self-care and comfort measures. But if a pregnant woman doesn’t have active involvement from a health care professional to motivate, support or guide her, she might not be able to incorporate these important self-care activities. Nurses and nursemidwives are in an ideal position to play a leadership role in working with
396
Nursing for Women’s Health
their physician colleagues as well as other members of the health care team to help women cope with and manage the discomforts of late pregnancy, and to help them avoid potential negative maternal and fetal health outcomes of elective inductions. NWH
References American College of Obstetricians and Gynecologists (ACOG). (2013a). Committee opinion no. 579. Definition of term pregnancy. Obstetrics & Gynecology, 122, 1139–1140. doi:10.1097/01. AOG.0000437385.88715.4a American College of Obstetricians and Gynecologists (ACOG). (2013b). Committee opinion no. 561. Nonmedically indicated early-term deliveries. Obstetrics & Gynecology, 121, 911–9115. doi:10.1097/01. AOG.0000428649.57622.a7 American College of Obstetricians and Gynecologists (ACOG). (2013c). Committee opinion no. 559. Cesarean delivery on maternal request. Obstetrics & Gynecology, 121, 904–907. doi:10.1097/01. AOG.0000428647.67925.d3.
Clark, S. L., Miller, D., Belfort, M., Dildy, G., Frye, D., & Meyers, J. (2009). Neonatal and maternal outcomes associated with elective delivery (electronic version). American Journal of Obstetrics & Gynecology, 200, 156.e1–156.e4. Retrieved from dx.doi.org/10.10161/j. ajog.2008.08068 Deutsch, H. (1973). The Psychology of Women: Volume 2—Motherhood. New York: Bantam Books, Inc. Eunice Kennedy Shriver National Institute on Child Health and Human Development. (2011). Increasing awareness of late preterm birth. Retrieved from www.nichd.nih.gov/news/ resources/spotlight/Pages/021811CME-CE-program.aspx Hoffmire, C. A., Chess, P. R. Ben Saad, T., & Glantz, J. C. (2012). Elective delivery before 39 weeks: The risk of infant admission to the neonatal intensive care unit. Maternal Child Health Journal, 16(5), 1053–1062. doi:10.1007/ s10995-011-0830-9 Spong, C. Y. (2013). Defining “term” pregnancy: Recommendations from the Defining “Term” Pregnancy Workgroup. Journal of American Medical Association, 309(23), 2445–2446. doi:10.1001/jama.2013.6235 Tita, A., Landon, M., Spong, C., Lai, Y., Levano, M. D., Varner, M. W., … Mercer, B. (2009). Timing of elective repeat cesarean delivery at term and neonatal outcomes. New England Journal of Medicine, 360(2), 111–120. doi:10.1056/ NEJMoa0803267
Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). (2015). 40 Reasons to go the full 40.
Volume 19
Issue 5