Although much has been written about helping women and their families cope with loss related to childbearing, little exists in the literature to guide and support the midwives who witness these losses. We conducted qualitative interviews globally with 22 midwives from nations located on six different continents to begin exploring common themes of experiences and coping methods of midwives involved in adverse perinatal outcomes. The concept of critical incident stress (CIS) is presented as a framework for understanding practitioner reactions that occur after adverse outcomes. Implications for practice, education, and continued research are addressed.
The use of exogenous oxytocin to induce or augment labor has increased in recent years. This literature-informed review examines the action of this medication and the potential associated complications, with an evaluation of current professional practice guidelines. A brief history of the use of exogenous oxytocin for labor induction or augmentation is presented. In addition, risk management strategies for the prevention of oxytocin-related adverse outcomes and subsequent litigation are identified.
Professional liability litigation is playing an increasing role in the practice of women's health care in this country. Although the impact of litigation on obstetricians' practices has been widely documented, data on the effect of litigation on midwifery practice are scant. The authors conducted a nationwide Web-based survey of American College of Nurse-Midwives (ACNM) members about the experience of being involved in litigation. The survey was completed by 600 midwives (17.5% response rate). Of those midwives completing the survey, 152 (25.3%) had been named in a lawsuit at least once during their midwifery careers. The litigation cases had been resolved for 114 (75%) of these respondents at the time of the survey. Forty-one (36%) reported being dropped from the case, even though the litigation continued without their involvement. Another 54 individuals (47.4%) were involved in cases that were settled before going to court, and an additional 10 cases (8.8%) were dropped without a settlement. Of the nine lawsuits (7.9%) that went to court, four favored the plaintiff (3.5%) and five (4.4%) favored the defendant. Future surveys are needed to better define the relationship between the practices of midwives and medical malpractice litigation.
Recommendations for improving clinical practice and avoiding litigation based on findings from the closed claims analysis include, but are not limited to, the need for thorough and accurate documentation in practice, appropriate and timely consultation and collaboration, and the presence of practitioners whose clinical skills match the level of care assessed to be necessary for each woman for whom care is offered.
The relation of cortisol reactivity and self-report anxiety to perinatal outcomes was examined in a sample of 38 primiparous adolescents. Maternal cortisol and anxiety levels obtained in the first half of pregnancy and in mid-third trimester were found to be related to the gestational age of newborns, with higher levels of cortisol and/or anxiety predicting greater chance of pre- or postmature birth. However, when measured over time, a greater increase in cortisol levels was more predictive of positive perinatal outcomes, such as no meconium in labor. These findings suggest that certain levels of maternal reactivity/anxiety are necessary for positive perinatal outcomes.
Lawsuits among midwives were significantly related to exposure to births over time. Practice patterns and job security were not greatly affected by the experience of a lawsuit. Future cyclic surveys are needed to track the frequency of litigation and the outcomes that lead to lawsuits and to better define the relationships between midwifery practice and medical malpractice litigation.
A prospective, longitudinal investigation of the relation between cortisol reactivity, self-report anxiety and labor and delivery outcomes was undertaken in a sample of non-urban pregnant adolescents. Cortisol and anxiety levels obtained in the first half of pregnancy and again in mid-third trimester were found to be related positively to several individual negative labor and delivery outcomes, as well as to a summary score of negative maternal intrapartal outcomes. However, when changes in cortisol and anxiety over pregnancy were examined, greater increases in cortisol and anxiety over time were negatively related to individual negative intrapartal outcomes, as well as to the maternal intrapartal outcomes summary score. Findings indicate that while an assessment of how individuals react to stress at certain points during pregnancy may be predictive of intrapartal outcomes, longitudinal examinations of gravid women's reactivity/anxiety states may be more indicative of their psychophysiological preparation for the intrapartum, and may be more predictive of outcome.
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