Point-of-care ultrasound education needs for nurse practitioners in primary care settings: An integrative review

Point-of-care ultrasonography (POCUS) is the process of operating a compact ultrasound machine at a patient’s location and immediately integrating the images generated into patient care. POCUS can help nurse practitioners (NPs) make more accurate diagnoses, facilitate safer procedures, and bridge health care access gaps in resource-limited settings such as primary care; however, it is widely agreed that POCUS is operator-dependent and that appropriate education is required to competently operate the device. This integrative review sought to determine what education NPs need to competently operate POCUS in primary care and it was found that there is no data specific to NPs; much of the available information is instead within the medical literature. Given the numerous benefits of POCUS for improving patient care and health care systems efficiency, NPs must urgently determine their POCUS education needs as they have ethical and legal obligations, in addition to a professional responsibility to ensure safe, high-quality patient care

Improving access to ultrasound imaging in northern, remote communities

Access to healthcare services—including access to medical imaging—is an important determinant of health outcomes. This thesis aims to improve understanding of and address gaps in access to ultrasound imaging for patients in northern, remote communities, and advance a novel ultrasound technology with the ultimate goal of improving patient care and health outcomes. This thesis first brings greater understanding of patients’ perceptions of access and factors which shape access to ultrasound imaging in northern, remote communities in Saskatchewan, Canada. A qualitative study was performed using interpretive description as a methodological approach and a multi-dimensional conceptualization of access to care as a theoretical framework. The study identified barriers which patients in northern, remote communities face in accessing ultrasound imaging, and demonstrated that geographic remoteness from imaging facilities was a central barrier. To determine whether disparities in access to ultrasound imaging resulted in disparities in utilization of ultrasound services, two population-based studies assessed the association between sociodemographic and geographic factors and obstetrical and non-obstetrical ultrasound utilization in Saskatchewan. In the first study investigating obstetrical ultrasound utilization, multivariate logistic regression analysis demonstrated that women living in rural areas, remote areas, and low income neighbourhoods, as well as status First Nations women, were less likely to have a second trimester ultrasound, an important aspect of prenatal care. In a second study investigating non-obstetrical ultrasound utilization across the entire provincial population, multivariate Poisson regression analysis similarly demonstrated lower rates of non-obstetrical ultrasound utilization among individuals living in rural and remote areas, individuals residing in low income neighbourhoods, and status First Nations persons. To address the barriers which patients in northern, remote communities face in accessing ultrasound imaging and to minimize disparities in ultrasound imaging utilization as identified in previous studies in this thesis, telerobotic ultrasound technology was investigated as a solution to improve access to ultrasound imaging. Using this technology, radiologists and sonographers could remotely manipulate an ultrasound probe via a robotic arm, thereby remotely performing an ultrasound exam while patients remained in their home community. A clinical trial comparing conventional and telerobotic ultrasound approaches was undertaken, validating this technology for obstetrical ultrasound imaging. To determine the feasibility of using telerobotic technology to establish an ultrasound service delivery model to remotely provide diagnostic ultrasound exams in underserved communities, pilot telerobotic ultrasound clinics were developed in three northern, remote communities. Telerobotic ultrasound exams were sufficient for diagnosis in the majority of cases, minimizing travel or reducing wait times for these patients. This technology was subsequently evaluated during a COVID-19 outbreak in northern Saskatchewan, demonstrating the potential of this technology to provide critical ultrasound services to an underserved northern population and minimize health inequities during the COVID-19 pandemic. An economic evaluation was performed to compare a service delivery model using telerobotic ultrasound technology to alternative service delivery models. Telerobotic ultrasound combined with an itinerant sonographer service was found to be the lowest cost option from both a publicly funded healthcare payer perspective and a societal perspective for many northern, remote communities. This thesis provides key insights for health system leaders seeking improved understanding and novel solutions to improve access to ultrasound imaging in northern, remote communities. Findings suggest that telerobotic ultrasound is a viable solution to improve access to ultrasound imaging and reduce costs associated with ultrasound service delivery. Evidence in this thesis may be used to help improve ultrasound services and health equity for patients in underserved northern, remote communities. Continued respectful collaboration with northern, remote, Indigenous peoples and communities will be a critical aspect to ensure that ultrasound services meet community needs

To cut or not to cut? Episiotomy in vacuum extraction

BACKGROUND AND AIMS Obstetric anal sphincter injury (OASIS) may cause anal incontinence, as well as sexual dysfunction and psychological trauma. Mediolateral and lateral episiotomy have been shown to be protective against OASIS in nulliparous women delivered by vacuum extraction (VE). The technique and trigonometric properties of an episiotomy may be important for its protective effect. The aim of the thesis was to explore episiotomy in Sweden. Firstly, we aimed at investigating the effect of episiotomy in nulliparous women at VE. Secondly, we aimed at exploring the attitudes towards, and knowledge about, episiotomy among doctors. Finally, we wanted to find out if an episiotomy might cause injury to the levator ani muscles (LAM). The impact of advanced maternal age on delivery outcome was also explored. METHODS AND MAIN RESULTS Study I and II are register-based cohort studies based on data from the Swedish Medical Birth Register. In study I delivery outcome in women ≥40 years was explored. We compared nulliparous women ≥40 years (n=7796) with nulliparous women 25-29 years (n=264 262) after spontaneous onset and induction of labor between 1992-2011. The rate of OASIS, episiotomy, and low Apgar score was also investigated. We found a significantly higher rate of intrapartum cesarean section among women ≥40 years, both after spontaneous onset of labor (adjusted odds ratio (aOR) 3.07, 95%CI 2.81-3.35) and induction of labor (aOR 2.51, 95%CI 2.24-2.81). The risk of VE was also increased in women ≥40 years, both after spontaneous onset (aOR 1.71 95%CI 1.59-1.85), and induction of labor (aOR 1.45, 95%CI 1.28-1.65). We found no significant difference in rate of OASIS, episiotomy or low Apgar score. Overall, 79% of women ≥40 years had a vaginal delivery compared with 93% of women 25-29 years. In study II nulliparous women delivered by VE between 2000-2011 were included. Women without episiotomy (n=43 853) were compared to women with a lateral or mediolateral episiotomy (n=19 801). After statistical balancing using propensity score, episiotomy was associated with a reduction in OASIS from 15.5% to 11.8%, ie an average treatment effect -3.7% (95% CI -4.3 to -3.0). The numbers needed to treat (NNT) to prevent one OASIS was 27. The third-degree perineal injuries alone were reduced from 14.0% to 10.9% (-3.1, 95% CI -3.7 to -2.4) with NNT 32. The fourth-degree perineal injuries alone were reduced from 1.6% to 1.0 % (-0.6%, 95% CI -0.8 to -0.4). Fourth-degree perineal injuries required NNT 172. Study III was a web-based questionnaire sent to the members of the Swedish Society of Obstetrics and Gynecology with a registered email in 2019 (n=2140). The response rate was 25% (n=432). The questionnaire addressed different aspects of VE and episiotomy and contained a picture of a crowning fetal head in which the respondents were asked to depict the episiotomy they would perform in the delivery room. The drawn episiotomies were translated into coordinates in a diagram. The episiotomies were categorized as lateral, mediolateral, midline or unclassifiable. In total, 57.8% (n=222) doctors reported performing episiotomy in less than 50% of VE deliveries. We found that only 54% of the doctors drew what could be considered a protective episiotomy. Furthermore, doctors in Sweden rated episiotomy as the least important measure to prevent OASIS in VE. Study IV was a descriptive prospective cohort study, examining if lateral episiotomy causes an iatrogenic LAM injury. Sixty-three women delivered by VE who received a standardized lateral episiotomy were examined by 3D endovaginal ultrasound about one year after delivery. Five images were not possible to retrieve due to a broken hard drive, thus 58 women were included. Of these 58 women, 12 had a visible LAM injury (20.7%, 95%CI 10.9-32.9). This is a significantly lower proportion than the stipulated 50% (p<0.001) of women. Two (16.7%, 95% CI 2.1-48.4) of 12 women had an ipsilateral LAD (p=0.02, compared with the stipulated proportion of 50%). CONCLUSION In conclusion, trial of labor may be worthwhile in women ≥ 40 years. Episiotomy seems to have a protective effect of OASIS in a Swedish population of nulliparous women with VE. A small majority of doctors in Sweden could depict a protective episiotomy. Our studies support that doctors are able to continue performing lateral episiotomies without risk of cutting the LAM

Effects of prenatal exercise on fetal heart rate, umbilical and uterine blood flow: a systematic review and meta-analysis

Objective To perform a systematic review and meta-analysis examining the influence of acute and chronic prenatal exercise on fetal heart rate (FHR) and umbilical and uterine blood flow metrics. Design Systematic review with random-effects meta-analysis and meta-regression. Data sources Online databases were searched up to 6 January 2017. Study eligibility criteria Studies of all designs were included (except case studies) if published in English, Spanish or French, and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone [“exercise-only”] or in combination with other intervention components [eg, dietary; “exercise + co-intervention”]), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcomes (FHR, beats per minute (bpm); uterine and umbilical blood flow metrics (systolic:diastolic (S/D) ratio; Pulsatility Index (PI); Resistance Index (RI); blood flow, mL/min; and blood velocity, cm/s)). Results ‘Very low’ to ‘moderate’ quality evidence from 91 unique studies (n=4641 women) were included. Overall, FHR increased during (mean difference (MD)=6.35bpm; 95% CI 2.30 to 10.41, I2=95%, p=0.002) and following acute exercise (MD=4.05; 95% CI 2.98 to 5.12, I2=83%, p\u3c0.00001). The incidence of fetal bradycardia was low at rest and unchanged with acute exercise. There were no significant changes in umbilical or uterine S/D, PI, RI, blood flow or blood velocity during or following acute exercise sessions. Chronic exercise decreased resting FHR and the umbilical artery S/D, PI and RI at rest. Conclusion Acute and chronic prenatal exercise do not adversely impact FHR or uteroplacental blood flow metrics

Childbirth Education in Jordan: Content, Feasibility and Challenges of Implementing a Childbirth Education Program in Jordan

No childbirth education (CE) programs are available in the public sectors in Jordan. Many studies from Jordan recommended that pregnant women be educated about their health needs during pregnancy and childbirth. From the literature, CE programs were found to have positive effects on pregnancy and childbirth outcomes. Four focus groups with pregnant women, midwives and physicians were conducted to examine the perceptions of pregnant women, midwives and physicians regarding the content, feasibility, and challenges of implementing a CE program in Jordan. The 4 focus groups, two with pregnant women (one group with 8 primiparous women and one group with 6 multiparous women), one with 8 midwives, and one with 6 physicians were presented with the content, timing, and a description of three existing CE programs. Findings indicated that pregnant women’s sources of knowledge about pregnancy and childbirth were mainly from other females and doctors but not from midwives. Younger pregnant women reported the Internet as an important source of pregnancy and childbirth knowledge. Findings showed that women were not sure of what they wanted to learn. Midwives and physicians wanted to include warning signs, physical exercises, psychological changes, vii nutrition, breast feeding, newborn heath, sexually transmitted diseases, pain management, postpartum physiology and care, family planning, and planning of pregnancy as content in a new CE program. All participants reported the need to include husbands in CE. However, husbands were considered a potential challenge to implementing a CE program. Other challenges were cost, staff, clients’ responses, and governmental policies. Midwives and physicians thought that CE should be included in free antenatal care. All participants reported support for a new CE program. Midwives and physicians suggested implementing the new program within the facilities of the Ministry of Health (MOH). This would decrease cost and the need for staffing for the new program. They suggested that the CE program could benefit from potential support from international sponsors that affiliate with the MOH. Potential benefits of CE could potentially help gain support from the MOH decision makers and the community in Jordan

Computer Assisted Learning in Obstetric Ultrasound

Ultrasound is a dynamic, real-time imaging modality that is widely used in clinical obstetrics. Simulation has been proposed as a training method, but how learners performance translates from the simulator to the clinic is poorly understood. Widely accepted, validated and objective measures of ultrasound competency have not been established for clinical practice. These are important because previous works have noted that some individuals do not achieve expert-like performance despite daily usage of obstetric ultrasound. Underlying foundation training in ultrasound was thought to be sub-optimal in these cases. Given the widespread use of ultrasound and the importance of accurately estimating the fetal weight for the management of high-risk pregnancies and the potential morbidity associated with iatrogenic prematurity or unrecognised growth restriction, reproducible skill minimising variability is of great importance. In this thesis, I will investigate two methods with the aim of improving training in obstetric ultrasound. The initial work will focus on quantifying operational performance. I collect data in the simulated and clinical environment to compare operator performance between novice and expert performance. In the later work I developed a mixed reality trainer to enhance trainee’s visualisation of how the ultrasound beam interacts with the anatomy being scanned. Mixed reality devices offer potential for trainees because they combine real-world items with items in the virtual world. In the training environment this allows for instructions, 3-dimensional visualisations or workflow instructions to be overlaid on physical models. The work is important because the techniques developed for the qualification of operator skill could be combined in future work with a training programme designed around educational theory to give trainee sonographers consistent feedback and instruction throughout their training

Quality predictors of abdominal fetal electrocardiography recording in antenatal ambulatory and bedside settings

Background: Fetal electrocardiography using an abdominal monitor (Monica AN24™) could increase the diagnostic use of fetal heart rate (fHR) variability measurements. However, signal quality may depend on factors such as maternal physical activity, posture, and bedside versus ambulatory setting. Methods: Sixty-three healthy women wore the monitor at home and 42 women during a hospital stay. All women underwent a posture experiment, and all home and 13 hospital participants wore the monitor during daytime and nighttime. The success rate (SR) of fHR detection was analyzed in relation to maternal physical activity, posture, daytime versus nighttime, and other maternal and fetal predictors. Results: Ambulatorily, the SR was 86.8% for nighttime and 40.2% for daytime. The low daytime SR was largely due to effects of maternal physical activity and posture. The in-hospital SR was lower during nighttime (71.1%) and similar during daytime (43.3%). SR was related to gestational age, but not affected by pre-pregnancy and current body mass index or fetal growth restriction. Conclusions: The success of beat-to-beat fHR detection strongly depends on the home/hospital setting and predictors such as time of recording, activity levels, and maternal posture. Its clinical utility may be limited in periods of unsupervised recording with physical activity or posture shifts

Birth matters: discourses of childbirth in contemporary American culture

In this project, I use a rhetorical-cultural approach to examine the multiple and often-contradictory messages circulating in contemporary American culture about the event of childbirth. Though many feminist scholars have shown how professional obstetrics’ view of physiological birth shapes medical practice and women’s experiences in hospitals, few have asked what the American public is learning about birth outside of the hospital, or why that knowledge might matter. In order to fill that gap, I trace a dominant narrative that positions institutionalized biomedical knowledge and technology as the exclusive producers of health and safety for birthing women and their babies in popular film and television, in the making of medical research and policy, and in the way the insurance industry frames women as consumers or recipients. I argue that it is not just in the delivery room that this ideology gets communicated, nor are birthing women the only ones affected by its messages. Rather, my analysis illustrates how this narrative has seeped into the fabric of how American society as a whole understands and engages with medicine, women’s bodies, and science. In the final chapter, in order to explore a growing resistance to this ideology, I turn to the discursive construction of birth in online media. Read alongside the mainstream narrative, the rhetoric in these online spaces illustrates how the stakes of this debate are not just about who gets to decide where and how women should have their babies, but ultimately over who gets to interpret and apply science. The battle over birth in this country is, as this dissertation shows, also a battle over the public’s understanding of institutionalized medicine’s exclusive claims to scientific knowledge. By exposing the ways that narratives about and within that system function to sustain it, and illuminating the ways that the organizing power of new media is generating resistance to that system, this project seeks to intervene in conversations about the cultural meanings of childbirth, about meaningful and ethical health care, and, ultimately, about the production and circulation of knowledge about science, medicine, and women’s bodies