1. Section Editor(s): Kriebs, Jan M. MSN, CNM, FACNM
  2. Perinatal Guest Editor
  3. Bakewell-Sachs, Susan PhD, RN, PNP, BC
  4. Neonatal Editor

Article Content

"That's not how we do it," "It's too hard," "What difference does it make," "I don't believe it"-Change can be hard. When our clinical expertise is challenged by new findings, or our personal beliefs are threatened; it is a natural response to push back. We may know that standardizing practice can improve pregnancy outcomes and newborn health but still cling to our preferred actions. Amid the push for quality initiatives and patient safety, unit culture can still exert itself to retard change as well. And the lack of high-quality evidence in obstetrics, whether randomized controlled trials, systematic reviews, or epidemiologic studies, leaves room for arguments.


So, what are we to do? We are encouraged to practice by the evidence, but the unreliability of some published evidence may lead nurses and physicians to conclude that it is too hard to sort out the quality of evidence and so refuse a change that will improve outcomes. In 2011, an article in Obstetrics and Gynecology examined the scientific evidence behind the American College of Obstetricians and Gynecologists practice bulletins.1 These bulletins are often considered the "gold standard" for clinicians. What the authors found demonstrates that we have a long way to go to ensure that the guidelines, policies, and protocols on which we depend are evidence based. Only 25.5% of the Obstetric Bulletins were based on category A evidence, defined as good and consistent scientific evidence. These results appear consistent with findings from other professional groups.1 McAlister and colleagues2 analyzed a series of medical guidelines and wrote that although the majority of treatment recommendations were based on randomized controlled trials, only half of those randomized controlled trials reported evidence relevant to the population for which the guideline was written and used direct rather than surrogate markers.


Articles in this issue address both changes in practice and the need to provide evidence-based counseling. Three articles focus on evidence specific to aspects of pregnancy and birth. In the first, Cypher writes about prevention of preterm birth, touching on the evidence for several predictive factors and interventions. The United States pays more for healthcare than any other country on a per capita basis, yet more than 12% of infants are born before 37 weeks of gestation.3 These 500 000 plus babies make the United States sixth on the list of countries contributing the highest number of preterm births to the global burden.4 Among the factors that increase risk are ethnicity, with African American women experiencing significantly higher risk than other groups, maternal age at the extremes of the reproductive years, multiple gestation, and, especially, women with a prior preterm birth.3 Nurses must be working with physicians, midwives, and administration to ensure that triage and management of women at risk for preterm birth adhere to interventions with documented effectiveness and avoid ineffective treatments.


Another way to prevent iatrogenic preterm birth is to prevent elective births before 39 weeks of gestation. Medically indicated delivery for maternal or fetal reasons can occur at any gestation when the uterus is no longer the safest place for a baby to grow. Although term birth has been defined as occurring at 37 or more completed weeks of pregnancy, neonates who have remained in utero until 39 or more weeks of gestation have lower rates of neonatal intensive care unit admission and respiratory distress.5,6 Avoiding elective induction prior to cervical ripening also decreases the risks of unnecessary cesarean birth.6 The March of Dimes has made elimination of elective birth before 39 weeks of pregnancy a centerpiece of its prematurity prevention efforts.7 Moore and Low present evidence regarding the reasons given for inducing labor in a healthy pregnancy. When the reasons reported by providers and women for taking an action that actually creates rather than reduces harm are understood, it becomes easier to see what maternal education and policy changes can be used to promote patient safety.


A third article focuses on an issue that has garnered attention but not necessarily changed provider practice on a wide scale: timing of cord clamping to allow placental transfusion. Mercer and Erickson-Owens have summarized here the increasing body of evidence that supports the benefits of delaying cord clamping regardless of the infant's gestation. A 2007 meta-analysis found no harm and significant reductions in anemia when cord clamping was delayed at least 2 minutes in term newborns.8 In very preterm (<32 weeks) infants, delaying the cord clamping at birth for as little as 30 to 45 seconds has been shown to have benefits in reducing risks of late-onset sepsis and intraventricular hemorrhage.9 These are only 2 of the numerous studies that have demonstrated the safety and benefit of this simple practice change. So why aren't we advocating for it?


The final article in the series addresses a completely different topic as Blendell and Fehr review information related to immunizations. Infant vaccination has been well demonstrated to be the best way to decrease the risks of common infections to young infants. While no intervention will prevent 100% of childhood infections or be 100% safe, there is no evidence that vaccines are related to autism and other developmental delays or that traces of chemicals found in vaccines carry risks.10 And although many people think of childhood illnesses as mild, unvaccinated children are 22 to 35 times as likely to acquire measles, an infection that can lead to pneumonia and encephalitis.11 When healthcare providers discuss immunization benefits and safety with parents, they are more likely to conclude that vaccination is safe.12 Two examples of the times to educate women and families about the importance of vaccines as a disease prevention tool range from offering the influenza or pertussis vaccines in pregnancy to explaining the neonatal hepatitis series.


Introducing or reinforcing evidence-based practice in an institution can provide challenges, particularly when there is resistance from within the administration or among clinicians. That does not excuse us from understanding what practices have solid evidence to support them as opposed to those that are based on convenience or provider preference. Nursing will always play an important role in promoting change-individually, by the counseling and education provided to women; as clinicians, by speaking out for change; and institutionally, by supporting and enforcing policies that are based on good evidence.


The topics for the neonatal section of this Evidence-Based Practice issue focus on neurodevelopmental care, design of neonatal intensive care units, and a study on cord stump care. The articles include an integrative literature review, a systematic literature review, and a comparative study on cord stump care. In addition, the neonatal columns focus on describing integrative and systematic reviews and Internet resources for evidence-based practice.


Lubbe, Van der Walt, and Klopper present a comprehensive investigation of neurodevelopmental supportive care using an integrative literature review. The investigation yielded 16 studies that met the methodological quality, using research methods other than clinical trials. The review was designed to provide the evidence base of neurodevelopmental supportive care for the preterm infant to support individual elements that should be included in a comprehensive care model.


Neonatal intensive care unit design has been found to significantly affect outcomes for infants, families, and staff. Shahheidari and Homer present a systematic review that explored the main features of neonatal intensive care units design to determine advantages and limitations of the designs with regard to outcomes for infants, parents, and nurses. The review yielded 2 main designs, open bay and single-family room, with the single-family room found to be superior for infant care and parent satisfaction. Key factors associated with improved outcomes are presented and discussed.


Nurses routinely provide neonatal cord care, with practices varying. Liu, Lee, Kuo, and Lien present the results of their research in Taiwan comparing the effects of using alcohol, natural drying, and salicylic sugar powder on umbilical cord detachment in a high humidity environment. While natural drying and salicylic sugar powder are safe and effective methods, salicylic acid was found to have the lowest rates of colonization and shortest time to cord separation.


-Jan M. Kriebs, MSN, CNM, FACNM


Perinatal Guest Editor


Assistant Professor and Director


Division of Midwifery


Department of Obstetrics,


Gynecology and Reproductive Sciences, University of Maryland,


Baltimore, Maryland


-Susan Bakewell-Sachs, PhD, RN, PNP, BC


Neonatal Editor




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2. McAlister FA, van Diepen S, Padwal RS, Johnson JA, Majumdar SR. How evidence-based are the recommendations in evidence-based guidelines. PLoS Med. 2007;4:e250. [Context Link]


3. Martin JA, Hamilton BE, Ventura SJ, et al. Births: final data for 2009. Natl Vital Stat Rep. 2011;60(1):1-70. [Context Link]


4. World Health Organization. Born too soon: the global action report on preterm birth. Accessed May 27, 2012. [Context Link]


5. Oshiro BT, Henry E, Wilson J, et al. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol. 2009;113(4):804-811. [Context Link]


6. Clark SL, Miller DD, Belfort MA, Dildy GA, Frye DK, Meyers JA. Neonatal and maternal outcomes associated with elective term delivery [published online ahead of print December 25, 2008]. Am J Obstet Gynecol. 2009;200(2):156.e1-156.e4. [Context Link]


7. March of Dimes. Prematurity Prevention Resource Center. Elimination of non-medically indicated (elective) deliveries before 39 weeks gestational age: quality improvement toolkit. Accessed May 27, 2012. [Context Link]


8. Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates-systematic review and meta-analysis of controlled trials. JAMA. 2007;297(11):1241-1252. [Context Link]


9. Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized controlled trial. Pediatrics. 2006;117(4):1235-1242. [Context Link]


10. Centers for Disease Control and Prevention. Vaccine safety. Accessed May 27, 2012. [Context Link]


11. Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. N Engl J Med. 2009;360:1981-1988. [Context Link]


12. Smith PJ, Kennedy AM, Wooten K, Gust DA, Pickering LK. Association between health care providers' influence on parents who have concerns about vaccine safety and vaccination coverage. Pediatrics. 2006;118(5):e1287-e1292. [Context Link]