Transforming nursing's vision: history, holism, and the health care system.
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Delivery of Health Care↗
Biomedical subjects
M A Morgan
Publications and source records attributed to M A Morgan.
Cervical assessment: visual or digital?
Our hypothesis for this study was that visual cervical assessment is not equivalent to digital assessment in patients with uterine contractions. We compared visual with digital cervical examinations done on 133 gravid women evaluated in the labor and delivery department because of uterine contractions. Patients at 27 weeks' gestation or more, subjectively in early labor, were prospectively entered into the study. Cervical dilatation and effacement were determined by two separate examiners blinded to each other's assessment, one by digital examination and the other by visual examination, in random order no more than 5 minutes apart. Eight of 133 patients were excluded from data analysis because of inability to visualize the cervix during speculum examination. Data analysis was done with correlation coefficient and the Bland and Altman test for agreement of two clinical measurements. Visual examination only underestimated actual cervical dilation by 0.60 cm (95% confidence interval [CI] 0.58 to 0.62 cm) and the limits of agreement were -2.06 cm (95% CI -2.02 to -2.09 cm) to 3.25 cm (95% CI 3.21 to 3.29 cm). Similarly, visual assessment underestimated effacement by 14.2% (95% CI 13.7% to 14.6%) and the limits of agreement were -41.3% (95% CI -40.5% to 42.0%) to 69.9% (95% CI 68.8% to 70.4%). In conclusion, cervical assessment in patients with uterine contractions who are thought to be in labor by visual speculum examination is not equivalent to that by digital examination. This difference seems to only be clinically significant if the cervix is more than 3 cm dilated.
Adult↗
Advanced maternal age: perinatal outcome when controlling for physician selection.
OBJECTIVE: Our purpose was to determine whether differences in maternal outcome because of maternal age could be controlled by the elimination of bias in physician selection. STUDY DESIGN: We performed a case-control study that compared pregnancy outcomes of 164 patients delivered at our institution at > or = 40 years old with outcomes in a control group consisting of the next two deliveries by the same attending physician of women with ages 20 to 29 years. Retrospective analysis of the antepartum and intrapartum records was done to compare clinical outcome. RESULTS: We observed a significant increased incidence of nulliparous cesarean delivery (p = 0.046), elevated results of glucose screens with a 50 gm load (p = 0.00002), and hypertension throughout pregnancy in the older patients in spite of controlling for physician selection. The older patient group was more likely to have used assisted reproductive techniques (p = 0.000005) and had higher baseline weights (p = 0.001) and maximum pregnancy weights (p = 0.042). However, the neonatal outcome was similar in both groups. Despite controlling for physician selection, we demonstrated increased rates of abdominal delivery, glucose intolerance, and hypertension in older patients. Fetal and neonatal outcomes were similar in both groups. CONCLUSION: Women > or = 40 years old tend to have an increased incidence of a few pregnancy-related complications, even when controlling for physician selection.
Adult↗
The risk of periventricular-intraventricular hemorrhage with vacuum extraction of neonates weighing 2000 grams or less.
OBJECTIVE: The objective of this retrospective study was to test the hypothesis that vacuum extraction of neonates with a birth weight < or = 2000 gm is associated with an increased risk of periventricular-intraventricular hemorrhage (PV-IVH). STUDY DESIGN: One hundred sixty-eight neonates weighing < or = 2000 gm were entered into this case control study. Fifty-six neonates delivered by silicone-rubber vacuum comprised the study group. For every infant born by vacuum-assisted delivery, two spontaneously delivered neonates served as controls (n = 112) and were matched for best obstetric gestational age (within 1 week), delivery date within 1 year, and birth weight < or = 2000 gm. Maternal and neonatal medical records were reviewed for demographic variables, antenatal complications, indication for vacuum-assisted delivery, neonatal birth weight, Apgar scores, umbilical cord blood gas values, and neonatal morbidity including the incidence of PV-IVH. All perinatal outcome variables were compared between the vacuum-assisted and spontaneously delivered groups. RESULTS: Both groups were similar with regard to maternal age, parity, antepartum complications, gestational age at delivery, neonatal birth weight, and gender. Both groups were also similar with regard to the incidence of 1-minute Apgar score < 5, small for gestational age, cephalhematoma, birth trauma, respiratory distress syndrome, hyperbilirubinemia, and sepsis. There was a significant increased incidence of 5-minute Apgar scores < 7 in the vacuum-assisted group (p = 0.04). No significant difference was observed in the incidence of PV-IVH grades 1 through 4 (21.4% vacuum group vs 16.1% control group, odds ratio 1.42, 0.58 to 3.45). CONCLUSION: Indicated use of the silicone-rubber vacuum to assist vaginal delivery of neonates weighing < or = 2000 gm does not appear to be associated with an increased risk of PV-IVH or other neonatal complications.
Case-Control Studies↗
Does cesarean section decrease the incidence of major birth trauma?
OBJECTIVE: To determine whether the increase in frequency of cesarean section is associated with a decreased incidence of major birth trauma. STUDY DESIGN: A retrospective cohort study was performed evaluating all neonatal cases of major birth trauma from January 1989 to December 1994. Major birth trauma was defined as peripheral plexus or nerve injuries, fractures, or lacerations. The data were grouped into two mutually exclusive periods (January 1989 to December 1990 vs January 1991 to December 1994) in which a significant difference in the cesarean section rate was known. RESULTS: Of 17,957 deliveries during the period, 141 cases of birth trauma occurred. One hundred thirty-seven of the 141 medical records were available for review, and 116 were classified as having had major birth trauma and were included in the study. The overall incidence of major birth trauma was 6.5/1000 deliveries. During the two-year period (January 1989 to December 1990), 18.3% of deliveries were by cesarean section and the major birth trauma rate was 8.4/1000 deliveries. During the following 4 years, the cesarean section rate was 22.3% and the major birth trauma rate was 5.3/1000 deliveries. Significant differences in the birth trauma chi(2) = 6.12, p = 0.013) and cesarean section (chi(2) = 40.80, p < 0.001) rates were observed. Controlling for the mode of delivery lessened the association between time period and birth trauma incidence (chi(2)MH = 3.28, p = 0.07). A significant decrease in the occurrence of major birth trauma in neonates delivered by cesarean section in the later period was discovered (relative risk = 0.46, 95% confidence interval 0.22 to 0.97). This decrease appeared to be mediated by a decrease in total lacerations between the periods (chi(2) = 11.76, p < 0.001), because the rates of other types of major birth trauma did not differ in neonates delivered by cesarean section or the vaginal route. CONCLUSIONS: With a 4% increase in rate of cesarean section at our institution, a significant decrease in the occurrence of major birth trauma was observed. This finding cannot be explained by a decreased risk of neonatal trauma in patients delivering vaginally, but rather by a decreased risk of neonatal trauma at cesarean section during the latter period.
Birth Injuries↗