The impact of antenatal cluster management on maternal delivery and postpartum rehabilitation

Abstract

Objective

Pregnancy care can improve maternal pregnancy outcomes. Cluster nursing, an evidence-based, patient-centered model, enhances pregnancy care, can provide patients with high-quality nursing services, has been widely used in clinical practice in recent years. However, most previous studies evaluated cluster nursing program only for a single clinical scenario. In this study, we developed and implemented a antenatal cluster care program for various prenatal issues faced by puerpera to analyze its application effect.

Methods

This is a historical before and after control study. 89 expectant mothers who had their prenatal information files registered in the outpatient department of a grade III, level A hospital from June 2020 to September 2021 were finally enrolled in observation group, and received prenatal cluster management. Another set of 89 expectant mothers from January 2019 to December 2019 were included in the control group and received traditional routine prenatal management. The effect of cluster nursing management on maternal delivery and postpartum rehabilitation was evaluated and compared between the two groups.

Results

Compared with the control group, the observation group had a significantly higher natural delivery rate, better neonatal prognosis, higher rates of exclusive breastfeeding, lower incidence of postpartum complications, shorter postpartum hospital stay, better postpartum health status, and higher satisfaction with nursing services. Compared with before intervention, the SAS and SDS scores of the observation group showed significant improvement after intervention.

Conclusion

Antenatal cluster care is beneficial to improve maternal and neonatal outcomes, and can have positive effects on natural pregnancy and breastfeeding, while improving the multimedia health education ability of medical care and emphasizing the importance of social support.

Introduction

Although childbirth is a natural physiological process, many expectant mothers, especially those who are pregnant for the first time, experience anxiety, depression, fear of childbirth, and other negative psychological states, often coupled with a limited understanding of pregnancy, which are not conducive to the childbirth process, postpartum rehabilitation, and newborn feeding and care. In 2018, the World Health Organization proposed new recommendations that women should have access to quality midwifery services for each delivery, including the right to be treated with respect and dignity, choosing their own labor caregiver, having good rapport and clear communication with obstetric staff, being offered pain relief options during labor, and moving around and choosing their own birthing position during delivery [1]. Therefore, maternal prenatal care aimed at improving pregnancy outcomes and postpartum rehabilitation is particularly important and urgent.

In recent years, advances in medical technology have rendered traditional nursing models irrelevant, and current nursing care paradigms emphasize patient-centered and holistic nursing interventions [2, 3]. Cluster management has emerged as a new management concept. This is a structured and comprehensive approach to offering comprehensive interventions for diseases [4, 5]. and has been used in the clinical management of several diseases worldwide. It is a scientific nursing model that strictly follows the evidence-based medicine, which systematically and organically integrates a series of proven effective nursing measures, achieving effective and evidence-based nursing through continuous and integrated management, and providing patients with the most optimized medical care services possible. Effective antenatal cluster management programs can enable expectant mothers to master basic information about pregnancy, self-care, self-management during delivery and perinatal care, breastfeeding, and newborn care, as well as staying healthy during pregnancy, so as to ensure a smooth delivery and the safety of expectant mothers and infants [6, 7]. A study showed that antenatal health education was effective in not only alleviating but also significantly improving adverse psychological states in pregnant women, thus improving their compliance with medical treatment [8]. Heaman et al. [9]. found that offering maternal health care services improved maternal pregnancy outcomes and reduced the incidence of complications. However, previous studies mostly focused on a single cluster care program for a specific clinical problem. In this study, we formulated and implemented a complete set of systematic cluster care programs for various problems prone to pregnant women, which innovatively integrated teach-back method into management strategies and implemented intervention for spouses simultaneously.

Materials and methods

Study respondents

This is a historical control study. The study sample consisted of expectant mothers who were registered as outpatients in a grade III, level A hospital. The sample initially included 92 cases of expectant mothers who had their prenatal information files registered in the outpatient department of the hospital during the perinatal period from June 2020 to September 2021. Among them, three patients were lost to follow-up, and a final total of 89 patients were included in the observation group.

The control group consisted of 89 cases of expectant mothers who did not receive antenatal cluster management and had their prenatal information files registered in the outpatient department of the hospital during their perinatal period from January 2019 to December 2019. We retrospectively analyzed their clinical data as the control group.

Inclusion and exclusion criteria

Inclusion criteria: (1) expectant mothers whose case files included complete information with detailed data available; (2) aged between 20 and 41 years; (3) singleton pregnancy; (4) in good physical health without pregnancy-related complications such as gestational diabetes, hypertension, heart disease, or edema during pregnancy; (5) no communication difficulties or cognitive impairments; and (6) consented to participate in this study after being explained about the study.

Exclusion Criteria: (1) expectant mothers with an overdue pregnancy; (2) expectant mothers with high risk factors for postpartum hemorrhage; (3) scar pregnancy; (4) multiparous women who had previously delivered infants with developmental abnormalities.

Methods

Intervention in the observation group

Expectant mothers in the observation group were involved in the antenatal cluster management program during the perinatal period in the outpatient clinic. All the expectant mothers joined the antenatal WeChat group for health education. During pregnancy, awareness lectures were shared by the team on the WeChat group, and they had at least two consultations with the specialist, once in the midwife’s outpatient clinic and once in the breastfeeding guidance outpatient clinic.

Cluster management strategy

This study was carried out by a research team consisting of nine doctors and nurses. The team was led by the head nurse of the obstetrics and gynecology department; the head nurse of the mother and baby unit and the head nurse of the obstetrics department were responsible for quality control; two midwives and two obstetrics supervisor nurses implemented the interventions. A chief physician and a director of the ultrasound department were the instructors.

The research team developed an antenatal cluster management intervention strategy based on a review of the literature and adding inputs from their clinical experience and expertise. The specific interventions were as follows:

Creation of a health education module

The team conducted prenatal health education courses based on different stages of pregnancy, with a total of nine sessions held every Saturday for two consecutive months. The courses were posted in a WeChat group and conducted continuously in two-month cycles. The contents of the health education module were as follows:

Introduction to maternal health care

Psychological guidance

Expectant mothers tend to have negative psychological states such as anxiety, depression, fear, and so on. It is important to provide them with emotional support and care, and they must be encouraged to face their labor positively while maintaining an optimistic attitude. The women were trained in diaphragmatic breathing to help them manage negative emotions. If they were overly nervous, they were taught distraction techniques to help them manage their anxiety.

Dietary guidance

The expectant mothers were advised to have well-balanced meals and ensure that their water intake was adequate. They were encouraged to have a diverse diet based on their preferences, eat small but frequent meals, and avoid overeating. To prevent dehydration due to excessive sweating during the summer, they were asked to drink plenty of water. They were also reminded to maintain food hygiene and refrain from consuming food left outside overnight, frozen, or spicy foods. They were provided with a list of foods to be avoided by expectant mothers, including raw soy milk, raw green beans, cassava, fresh cauliflower, raw tomatoes, fresh bamboo shoots, crabs, Portulaca oleracea, coix seed, Trionychidae, and so on.

Advice on rest

All expectant mothers were advised to get 8 to 9 h of sleep per day, including a nap of around one hour. It was recommended to sleep in a left-lateral position.

Exercise recommendations

All the expectant mothers were advised to exercise appropriately and engage in activities such as walking, slow jogging, prenatal yoga, and other aerobic exercises to boost immunity.

Fetal monitoring

The expectant mothers were encouraged to self-monitor fetal movements, counting the number of movements once in the morning, once in the middle of the day, and once in the evening, for one hour each time. They were asked to visit the hospital immediately if they noticed any abnormalities.

Hygiene instruction

The expectant mothers were advised to pay attention to personal hygiene, such as regularly trimming their nails, washing hands frequently, using warm water to clean the external genital area, and regularly changing their inner wear.

Interpretation of B-ultrasound results during pregnancy

The Chief Physician of the ultrasound department explained the importance of B-ultrasound examination during pregnancy, as well as the B-ultrasound examination procedure and precautions that should be taken at various time points in the three stages of pregnancy.

Breastfeeding

• (1) The team explained the benefits of breastfeeding to expectant mothers and their families. The focus was on breast milk as the natural food for infants and its superiority to formula milk in enhancing their immune system.

• (2) The expectant mothers were taught breastfeeding techniques by demonstrations and other means. The nursing staff used a baby model to demonstrate breastfeeding posture, breastfeeding duration, and frequency, as well as other precautions to be followed. The team also taught the mothers how to burp their newborns correctly.

• (3) The expectant mothers were taught to recognize the baby’s hunger cues and breastfeed on demand, as well as to avoid excessive massaging of the breasts, which could cause mastitis. They were advised to avoid high-calorie and high-fat diets and eat light and easy-to-digest food. They were encouraged to have frequent and small meals, drink about 2000 ml of warm, boiled water per day, and avoid long gaps between meals and excessive water intake.

Preparing for labor

The expectant mothers were taught to keep ready items for the delivery, including menstrual pads, towels, drinking cups, straws, newborn diapers, and clothing. They were taught to recognize signs such as vaginal bleeding or premature rupture of the fetal membrane in the postpartum period that indicated that delivery was nearing. The expectant mothers and their family members were taught to identify the warning signs of labor and reach the hospital on time.

The team explained the normal process of delivery and encouraged the family members to assist the expectant mothers in using Lamaze childbirth breathing techniques to relieve labor pain. They were also taught to distract the expectant mother with music, conversation, and other methods to help divert attention from the pain and alleviate their discomfort. The expectant mothers were taught to use a bedpan for passing urine in the bed so as to prevent the bladder from filling up and slowing the descent of the fetal head.

Non-pharmacological pain management during labor

The team used video teaching and simulation scenarios to explain non-pharmacological methods of managing labor pain and the principles they are based on, including doula delivery, psychotherapy, seated labor, and airbag-assisted delivery.

Perineum care

The expectant mothers were educated about the puerperium period that lasts for 42 days, during which the mothers require proper rest. They were taught the importance of having a comfortable and conducive environment for them, with the indoor temperature maintained at 26–28℃, with care to be taken that the air conditioning vent does not directly blow towards them and the newborns. They were advised to have adequate ventilation in their bedroom by opening the windows for 30 min in the morning and 30 min in the evening.

The mothers were encouraged to wear loose and comfortable cotton clothes, change their inner wear regularly, and maintain adequate personal hygiene. They were asked to avoid contact with cold water as much as possible. They were encouraged to follow a diet that was light and nutritious. Drinking brown sugar water for 3 to 7 days to increase vitamin intake and prevent constipation was recommended. Additionally, they were advised that it was important to take care of their emotional well-being, including maintaining a positive mood and preventing postpartum depression, to facilitate their postpartum recovery.

Close monitoring of newborns for symptoms and responding to abnormalities

The mothers were instructed that after the delivery, the newborn baby would be subjected to a health examination, including checking if the baby’s limbs, skin, internal organs, and genitalia were normal, as well as testing the baby’s hearing. If neonatal jaundice was observed, the neonate was provided treatment such as blue light irradiation if necessary. The mother and her family members were taught umbilical cord care for the newborn and skills in dealing with nasal congestion, phlegm, hiccups, and so on.

Practical demonstrations of neonatal nursing

The team demonstrated techniques for bathing a newborn, handling the baby, and skin care using a baby model. The expectant mothers and their family members were taught how ensuring a comfortable posture for newborns could benefit their neurological and behavioral development. The team recommended that they cover newborns with soft bed sheets, wrap them in blankets to keep them warm, and apply skin care oil to the skin in the newborn’s armpits, groin, and neck folds. They were taught the importance of skin care for the newborn, especially the buttocks, to avoid rashes and skin inflammation.

Providing information about procedures following admission to the hospital for delivery

The team guided the pregnant women about completing the relevant procedures and examinations they had to undergo on admission to the hospital. The bed nurse helped them to familiarize themselves with the delivery room environment and introduced the department director, the doctor in charge of the bed, and the nurses to help alleviate any sense of unfamiliarity.

Micro-video education

• 1. The team created simple health education videos and screened them on a loop in the waiting room of the perinatal clinic.

• 2. A WeChat group was created for sharing prenatal information with the expectant mothers, and the nurse responsible for implementing the interventions regularly uploaded health education videos from Monday to Friday.

• 3. The intervener also responded to queries online every night from 19:30 to 20:30.

III Specialist outpatient counseling service

The team set up a midwife clinic that was staffed by a nurse practitioner on Tuesday mornings and a breastfeeding guidance clinic that was staffed by a senior nurse practitioner on weekdays. This was to help the expectant mothers consult specialists in case of any difficulties during pregnancy and resolve their issues.

It is in the COVID-19 period from June 2020 to September 2021 in China. If the expectant mothers had related symptoms and cannot reach the hospital, they would be guided online by the Internet hospital.

Quality control

To ensure the effective implementation of the cluster management measures, the team documented the following aspects in the intervention checklist: details of the videos on health education that were uploaded daily, a summary of the questions and answers provided online every evening, and the contents of the classes. The head nurse of the mother and baby ward and the head nurse of the delivery room monitored the implementation of the measures on Tuesdays and Fridays and responded to the difficult questions.

Intervention in the control group

Expectant mothers in the control group received routine clinical interventions, which included regular prenatal check-ups, the completion of a form to select their preferred mode of delivery, appropriate prenatal nutrition guidance inputs, supportive psychological interventions, follow-up and postpartum physical examination for the mothers conducted 42 days after delivery.

Observation indicators

(1) Delivery mode: natural childbirth rate, cesarean section rate. (2) Psychological state: the Zung Self-Rating Anxiety Scale (SAS) [10] and the Zung Self-Rating Depression Scale (SDS) [11] were used to evaluate the psychological state of the expectant mothers in the observation group pre- and post-intervention. Higher scores indicated higher negative emotions like anxiety and depression, respectively. (3) Neonatal outcomes: incidence of macrosomia, neonatal asphyxia, and infants with low birth weight. (4) Breastfeeding status of newborns: incidence of exclusive breastfeeding, mixed feeding, and formula feeding. (5) Complications, if any, among the postpartum mothers. (6) Comparison of the duration of hospitalization and health status in the 42-day postpartum medical examination of mothers in the two groups. (7) Satisfaction rating of the expectant mothers and their families based on the “Delivery Ward Nursing Service Satisfaction Survey” designed by the hospital, which consisted of 11 items to examine the quality of delivery ward nursing services from the perspective of the expectant mothers.

Statistical analysis

We used SPSS 22.0 statistical software to analyze the data. Measured data were represented as $\:\stackrel{-}{x}\pm\:s$, and the t-test was used for comparisons. Count data were expressed as relative numbers, and the χ² test was used for comparisons. The difference was considered statistically significant when the P value was < 0.05.

Results

Baseline characteristics of two groups

The comparison of baseline characteristics between the two groups of expectant mothers, including age, parity, gestational weeks, education level, and other factors, showed that all the P values were > 0.05, indicating that the two groups were comparable (Table 1).

The comparison of baseline characteristics between the two groups of expectant mothers, including age, parity, gestational weeks, education level, and other factors, showed that all the P values were > 0.05, indicating that the two groups were comparable (Table 1).

Table 1 Comparison of baseline characteristics between the two groups (n; %)

Comparison of delivery modes

The rate of natural childbirth among women in the observation group was significantly higher than that in the control group, P < 0.05 (Table 2).

Table 2 Comparison of delivery modes between the two groups (n; %)

Comparison of the pre- and post-intervention SAS and SDS scores in the observation group

The post-intervention SAS and SDS scores of mothers in the observation group were significantly better than the pre-intervention scores, P < 0.05 (Table 3).

Table 3 Comparison of pre- and post-intervention SAS and SDS scores of expectant mothers in the observation group (n; $\:\stackrel{-}{x}\pm\:s$; points)

Comparison of neonatal outcomes between the two groups

The adverse neonatal outcomes in the observation group were significantly lower than those in the control group, P < 0.05 (Table 4).

Table 4 Comparison of neonatal outcomes between the two groups (n; %)

Comparison of breastfeeding of newborns in the two groups

The rate of exclusive breastfeeding among mothers in the observation group was significantly higher than that in the control group, P < 0.05 (Table 5).

Table 5 Comparison of breastfeeding status of newborns between the two groups (n; %)

Comparison of postpartum complications in the two groups

The rate of postpartum complications in the observation group was significantly lower than that in the control group, P < 0.05 (Table 6).

Table 6 Comparison of the incidence postpartum complications between the two groups (n; %)

Comparison of duration of postpartum hospitalization and 42-day postpartum health status between the two groups

The duration of postpartum hospitalization of expectant mothers in the observation group was significantly shorter than that of the control group, and the mothers in the observation group had a significantly better health status in the postpartum 42-day health checkup when compared to mothers in the control group, P < 0.05 (Table 7).

Table 7 Comparison of duration of postpartum hospitalization and postpartum recovery scores between the two groups (n; $\:\stackrel{-}{x}\pm\:s$)

Comparison of the satisfaction ratings of expectant mothers and their families in the two groups

Expectant mothers and their families in the observation group reported a significantly higher satisfaction rating than those in the control group, P < 0.05 (Table 8).

Table 8 Comparison of satisfaction ratings among expectant mothers and their family members between the two groups (n; %)

Discussion

Cluster management is an emerging management mode developed in response to the increasingly refined nursing requirements of patients and is a contemporary model of care based on a holistic approach [12, 13]. This mode of care is delivered through a specially created cluster responsibility team that integrates and plans relevant interventions based on the characteristics of the disease and individual patient needs. The intervention plans that are developed in this system of nursing care are focused and holistic, thereby comprehensively improving the quality of medical and nursing care [13].

Pregnancy involves a prolonged and intense stress response, and most expectant mothers experience varying degrees of stress, anxiety, worry, and other negative emotions [14, 15]. Pregnancy requires periodic professional medical intervention, and the knowledge of health care during pregnancy is complicated, so scientific and systematic health education is particularly important. In this study, the systematic antenatal cluster management interventions yielded good results. It improved maternal-fetal outcomes and postpartum recovery, promoted natural childbirth and breastfeeding, and increased patient satisfaction. These findings may be attributed to the positive effects of diversified cluster management interventions implemented in the observation group. First of all, the cluster nursing scheme in this study covers various topics that may be encountered during pregnancy, including pregnancy diet activities, B-ultrasound interpretation during pregnancy, breastfeeding, labor preparation, non-medication analgesia delivery, postpartum care and newborn care. Systematic intervention measures targeting different stages each one relates to another, may have produced positive synergistic effects, thereby comprehensively improving maternal and neonatal outcomes. Secondly, we applied teach-back method in the intervention process, which changed the traditional hierarchical education model. It encouraged pregnant women to make statements and their spouses to supplement after each health education, and integrated evaluation and feedback throughout the entire education process. For information that is misunderstood or not understood, we will interpret repeatedly until they thoroughly understood and mastered it. In addition, scientific pregnancy knowledge and technical support provided by popular science videos from online pregnant women school, is beneficial for helping mothers truly master pregnancy and postpartum related knowledge and skills, reduce cognitive and behavioral biases, construct a scientific conception of pregnancy, and establish a sense of health responsibility, thus achieving the goal of actively participating in health management and improving self-management abilities. This also suggests that in future health education, emphasis should be placed on increasing the participation of research subjects. Moreover, during the management period, there were specialized nurses answered questions online every night to timely grasp the learning situation of pregnant women and enabled them to receive professional help from medical staff, which was helpful to enhance emotional support in learning, and stimulate their learning motivation.

Previous study [16]. showed that pregnant women in outpatient clinics without real-time supervision at home, resulting in poor compliance with health behavior, and maternal health behavior compliance is closely related to the prognosis. Therefore, this study provided simultaneous intervention for pregnant women and their spouses to help supervise pregnant women to adopt a healthy lifestyle in life, timely feedback to nurses to discuss and solve encountered problems in health management, and promote pregnant women to adopt health management behaviors through high levels of social support. In the process of providing information and emotional support to pregnant women, the subjective initiative and participation of spouses improved. They felt the important role of their own efforts in perinatal health management, and thus experienced the positive and happy feelings brought by their sense of self-worth. We found that the 42-day health examination rate of the observation group was statistically significantly higher than that of the control group, which also indicted that higher spouse participation is beneficial to improve the health education effect and health behavior compliance. Therefore, this nursing care model proved conducive to establishing a harmonious nurse-patient relationship.

However, this study still has significant limitations, mainly due to the research design itself. This is a historical before-after study of different cases. Selecting two groups of expectant mothers from different periods can evaluate the application effect faster and more economically. We ensured that pregnant women enrolled at the same time period receive the same intervention measures to eliminate volunteer bias. But at the same time, the results can be affected by individual differences exist among different cases and confounding factors from the different time conditions, and the effectiveness of the intervention is questionable. In the future, we need to explore more well-designed study to validate the current findings.

Conclusion

In conclusion, the antenatal cluster management program helped to improve the rate of natural childbirth and exclusive breastfeeding, ensure the safety of both mothers and newborns, promote postpartum recovery, and achieve higher satisfaction among users. This model of nursing care merits further promotion and clinical use.