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Best Practices for Assessing Fall Risk in Perinatal Units

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1 Best Practices for Assessing Fall Risk in Perinatal Units
NS 400 University of Alaska Anchorage Matrika Arrington, Nick Barney, MJ Jones, Mara Krey, Camille McArdle The following is a presentation on the best practices for assessing fall risk in perinatal units This presentation is presented by

2 Best Practices to Reduce Falls in Perinatal Units
Level of Evidence Citation Key Measures Setting and Sample Research Design Key Strengths and Weaknesses Results McCrory, J., Chambers, A., Daftary, A., & Redfern, M. (2011). Ground reaction forces during gait in pregnant fallers and non-fallers. Gait & Posture, 34, Level of Evidence: IV Walking velocity DV: Ground Reaction Forces IV: pregnant women Setting: Laboratory on the campus of the University of Pittsburgh Human Movement and Balance 41 pregnant females Sample, n=81 40 non pregnant females age 18-45 Retrospective Quasai-Experimental Non-Experimental Observational Strengths: Weaknesses: First Step toward demonstrating causation Easy to conduct No causation and correlation No intervention First and second trimester pregnant women have a slower walking velocity (1.34, 1.29m/s) compared to non-pregnant (1.47m/s). (p=0.048) Lord, S., Lloyd, D., & Li, S. (1996). Sensori-motor function, gait patterns and falls in community-dwelling women. Age and Ageing, (25), IV: Pregnant women DV: 80+ measurements of sensori-motor function. Most important: aged 22-99 Sample, n=183 Community Setting Group over 65 years of age: n=96 Non-experimental Prospective Immense amount of data collected Shows a great way to measure falls without making the event happen Not fully randomized due to convenience sample of young people Small number of faller group There was a difference between multiple fallers and non fallers of 0.08 SD. The p value was not <0.05 but increasing the sample size could make this result significant. Jang, J., Hsiao, K., Hsiao-Wecksler, E. (May 2008). Balance (perceived and actual) and preferred stance width during pregnancy. Clinical Biomechanics, 23(4): DV: balance & stance width IV: pregnancy 15 non-pregnant women 15 pregnant women Sample, n=30 Repeated measures Non-experimental Prospective New measurement techniques Addition of control challenges previous findings Loss of 3 study subjects & small convenience sample Low level of evidence & no intervention Significant sense of balance degradation, increased sway in the anterior-posterior direction (medial-lateral sway decreased), decreased falls & wider stances generally had better balance perception Hanson E, Månsson N, Ringsberg K, Håkansson A. falls among dizzy patients in primary healthcare: an intervention study with control group. International Journal Of Rehabilitation Research, 31(1):51-57. Level of Evidence: III IV: vestibular rehabilitation DV: self-perceived handicap r/t dizziness, balance, & falls among dizzy patients Sample, n=58 >65 yo patients “multisensory dizziness” not explained by other diagnosis non-randomized control Quasi-experimental non-equivalent control group control group (challenges previous studies non-control findings) DHI tool asked questions about their self-perceived handicap r/t dizziness by defining it as “dizziness or unsteadiness problems” shortened to accommodate lack of subject time commitment non-randomized group assignment loss of 13 subjects Vestibular rehab was ineffective at reducing falls & patients with poor outcome in “tandem stance with eyes open” assessment had twice the fall risk Day , L., Fildes, B., Gordon, I., Fitzharris, M., Flamer, H., & Lord, S. (2002). Randomized factorial trial of falls prevention among older people living in their own homes. BMJ: British Medical Journal, 325(7356), Level of Evidence: II DV: Quadriceps strength, balance IV: exercise Aged 70+ and living at home. Sample, n=1090 Participants homes in Australia. Convenience sample Experimental: Randomized Control Trial with a Full Factorial Design Most Significant Intervention to Prevent Falls: Exercise RCT, large sample, Intervention not too inconvenient for participants Study more than 5 years old Significant effect (P < 0.05) was observed for the combinations of interventions that involved exercise. Balance measures improved significantly among the exercise group. Tinker, S. C., Reefhuis, J., Dellinger, A., & Jamieson, D. (2010). Epidemiology of maternal injuries during pregnancy in a population-based study, 1997– Journal Of Women’s Health, 19(12), doi: = jwh Level of Evidence: VI Phone interviews with mothers 6 weeks to 2 years after the birth of healthy child. DV: Fall, No Fall IV: Pregnancy Arizona, California, Georgia, Iowa, Massachusetts, North Carolina, New Jersey, New York, Texas, Utah Sample, n=6609 Mothers Non-experimental Retrospective, population-based, case-control study Large sample, Subjects from multiple states across country, Diverse demographic & socioeconomic backgrounds Study limited by reliance on self-reported data, Mothers more likely to report only injuries given in examples by the interviewer than half of reported injuries were due to falls (51.6%) Slightly more Data suggests that the occurrence of falls becomes more likely as pregnancy progresses, with nearly 43% of reported falls occurring during the third trimester Maloni, J. A., & St. Pierre Schneider, B. (2002, May ). Inactivity: Symptoms associated with gastrocnemius muscle disuse during pregnancy. AACN Clinical Issues, 13(2), Level of Evidence: IV DV: gastrocnemius muscle reoxygenation time IV: length of hospital (antepartum) bed rest Convenience Sample of pregnant women prescribed antepartum bed rest Sample, n=65 Hospital antepartum unit Longitudinal, repeated measure study Inclusion and Exclusion criteria for population included Data collector education completed prior to enrollment of subjects Interrater reliability for PSC was established and assess quarterly to maintain reliability of 0.95 Convenience sample Small sample size No randomization Correlates the length of inactivity on muscle atrophy and the increased time needed for reoxygenation of muscle tissue on postpartum women who received antepartum bed rest. The length of recovery is dependent on the length of bed rest, but findings show that there the recovery period longer due to symptoms still reported at week 6 postpartum. Maloni, J. A., & Park, S. (2005). Postpartum symptoms after antepartum bed rest. Journal of Obstetric, Gynecology and Neonatal Nursing Clinical Research, 34, http://dx. doi.org/ / DV: physiological and psychological postpartum symptoms IV: antepartum bed rest Three perinatal tertiary care hospitals in two cities in the Midwest Sample, n=106 Convenience sample of pregnant women, with a single high-risk pregnancy and treated with antepartum bed rest Use of Postpartum Symptom Checklist (PSC) to gather data Exclusion criteria for population included musculoskeletal and neurological disorders Clarity needed when determining differences in symptoms of vaginal vs. cesarean deliveries – are symptoms related to delivery or extended bedrest Weakness: Length of hospital antepartum bed rest is associated with increased issues and symptoms postpartum. Since bed rest causes musculoskeletal and cardiopulmonary deconditioning ambulation will restore function, but since reconditioning takes at least 6 weeks or longer postpartum caution should be used to prevent falls. Dunning, K., LeMasters, G., & Bhattacharya, A. (2009, August 13). A major public health issue: The high incidence of falls during pregnancy. Maternal Child Health Journal , 14, /s participants were research via survey in the mail, telephone and internet questioned about falls during pregnancy. DV: falls Postpartum women contacted in Ohio, Kentucky, and Indiana communities Sample, n=3997 Females selected from birth certificate data; eligible if they had delivered within the last 8 weeks. Cohort Study Single Correlational Strengths Large Sample size Weakness Randomization when choosing sample Minimal Participant Bias Maternal inclusion criteria not specified within the study Medical record review limited Suggest that falls with this population are completely preventable; most associated with slippery floors, lack of appropriate footwear and using insufficient safety measures. Falls in the pregnant community are similar to those compared to the elderly. Butler, E., Colon, I., Druzin, M., Rose, J. (2006). Postural equilibrium during pregnancy: Decreased stability with an increased reliance on visual cues.  American Journal of Obstetrics and Gynecology, 195, 1104 – 1108.  doi: /j.ajog DV: change in postural stability (center of pressure) and the incidence of falls 12 Pregnant Women, 12 Nulligravid Women.  Exclusion criteria included any medical condition that affects postural stability. Sample, n=24 Non-experimental Correlational Control Group Study protocol was approved by Stanford Committee Informed Consent Unknown Attained Sample Small Sample Size Study Published in 2006 During the second and third trimester of pregnancy the center of pressure was wider resulting in a decline in postural stability and remains diminished 6 to 8 weeks post-delivery compared to the non-pregnant women who had a narrow center of pressure. Out of the 8 women who returned for the postpartum visit, 2 women reported sustaining a fall during their 2nd and 3rd trimester. For each center of pressure measurement the value of P is always P<0.05. Heafner, L., Suda, D. E., Casalenuovo, N. M., Leach, L., & Gawlinski, A. (2011). 'Catch a falling star': The development of the obstetric falls risk. doi: /j _10.x Level of Evidence: DV: Falling IV: Impatient Pregnant Women Proposed population in Phase III is 100epiduralized obstetric patients post anesthesia. Sample, n=100 Obstetric in-patients in Phase I and II. Quasi-experimental  Non-experimental: Developed by a panel of expert perinatal nurses & validated through literature review. Financially feasible Judgment of inexperienced nurses using OFRAS may be less accurate Study still in progress; sample size of Phase I & II unknown Phase I of the study was the development and implementation of Obstetric Falls Risk Assessment System (OFRAS); falls decreased from 6 to 1 in an 8 month period. Phase II –Systematic assessment of ante-, intra-, and postpartum patients using a scoring system to quantify fall risk. Seven obstetric patient falls and 14 near misses were analyzed retrospectively using the OFRAS. Preliminary analysis revealed additional risk factors which were then incorporated into the OFRAS. Phase III -Began by implementing the OFRAS into the EMR Matrika Arrington, Nick Barney, Michelle Jones, Mara Krey, Camille McArdle Summary of Evidence: Falls in the perinatal population are preventable. Anticipatory guidance with patient teaching would be effective at reducing incidences of falls (Dunning, et. al, 2009) Antepartum or at home bed rest duration information may be an assessment criteria to review upon receiving a postpartum patient to reduce the risk for falls (Maloni & Park, 2005) Patients with a decreased perception of balance might benefit from widening their stance (Jang, Hsiao, & Hsiao-Wecksler, 2008) Tandem stance with eyes open most effective at predicting fall risk. (Hanson, Mansson, Ringsberg, & Hakansson, 2008) 51.6% of all injuries reported during pregnancy were from falls. Falls more likely to be reported in the second and third trimesters Improved balance observed for combinations of interventions that involve exercise (Day et. al., 2002) During the second and third trimester of pregnancy the center of pressure is wider resulting in a decline in postural stability (Butler, Colon, Druzin & Rose, 2006) Evidence shows implementation of a fall risk tool specifically for pregnant women will decrease falls (Heafner, et. al., 2011) Importance: “falls are the most common cause of minor injury during pregnancy and are estimated to cause 17–39% of trauma associated with emergency department visits and hospital admissions, second only to motor vehicle crashes,” (Dunning et al., 2009). “Knowledge of characteristics specifically associated with injury among pregnant women can be used to help identify women who may be at higher risk for experiencing an injury during pregnancy and can potentially inform the development of prevention programs for women to reduce the risk of injury during pregnancy” (Tinker et. al, 2010). Future Research: •Based on lack of research: development of assessment tools controlled trials •Meta analysis to accurately determine the best assessment techniques Searchable Question: What are the best practices for assessing fall risk in the perinatal units? Databases Searched: CINAHL PubMed Google Scholar

3 Significance of the Problem
“falls are the most common cause of minor injury during pregnancy and are estimated to cause 17–39% of trauma associated with emergency department visits and hospital admissions, second only to motor vehicle crashes,” (Dunning et al., 2009, p. 720). “Knowledge of characteristics specifically associated with injury among pregnant women can be used to help identify women who may be at higher risk for experiencing an injury during pregnancy and can potentially inform the development of prevention programs for women to reduce the risk of injury during pregnancy” (Tinker et. al, 2010)

4 Searchable Question What are the best practices for assessing fall risk in the Perinatal units?

5 A major public health issue: The high incidence of falls during pregnancy (Dunning et al., 2009)
Non-experimental single correlational study, Level IV Participants reflecting on falls during pregnancy 3997 postpartum women Falls related to insufficient safety measures Strengths Large Sample size Minimal Participant Bias Randomization when choosing sample Weakness Medical record review limited Maternal inclusion criteria not specified within the study Dunning et al., conducted a non-experimental single correlational study with level IV evidence in which participants, women ranging from one to eight weeks postpartum, were surveyed via telephone, internet and mail querying them about falls that occurred during their pregnancies. Participants were randomly taken from the birth certificate public records department, population n= Dunning et al., 2009, reflected in their discussion about the socioeconomic, workforce as well as age factors of their population sample, but did not include data from maternal history such as the presence of hypertension, diabetes or some other type of musculoskeletal or neurological conditions. This may be related to the fact that access to medical record review was limited. Dunning et al., reflected that most fall were associated with slippery floors, lack of appropriate foot wear, and using insufficient safety measures. Conclusions made from this study are that falls with this population are completely preventable and anticipatory guidance with patient teaching would be effective at reducing incidences of falls, which does not answer the question of how to assess fall risk.

6 Postpartum symptoms after antepartum bed rest (Maloni, J. A
Postpartum symptoms after antepartum bed rest (Maloni, J. A., & Park, S. 2005) Strengths Use of Postpartum Symptom Checklist (PSC) to gather data Exclusion criteria included musculoskeletal and neurological disorders Weakness Clarification regarding vaginal vs. cesarean deliveries – are symptoms related to delivery or extended bedrest Non-experimental longitudinal study, Level IV evidence 106 post partum women prescribed bed rest during antepartum period Findings show that combined with bed rest recovery as well as delivery healing can put a perinatal patient at a risk for falls Maloni et al., 2005 conducted a non-experimental longitudinal study with level IV evidence that investigated the correlation of antepartum bed rest to the type of symptoms that occur during postpartum as well as their duration using a Postpartum Symptom Checklist. Due to compliance issue with confines of bed rest, Maloni et al., limited bed rest criteria to inpatient antepartum, because of compliance issues with at home bed rest. Since bed rest causes musculoskeletal and cardiopulmonary deconditioning ambulation will restore function, but since reconditioning takes at least 6 weeks or longer postpartum caution should be used to prevent falls. Antepartum or at home bed rest duration information may be an assessment criteria to review upon receiving a postpartum patient to reduce the risk for falls

7 Inactivity: Symptoms associated with gastrocnemius muscle disuse during pregnancy (Maloni & St. Pierre Schneider, 2002) Strengths Inclusion and Exclusion criteria Data collector education completed prior to enrollment of subjects Interrater reliability for PSC was established and assess quarterly to maintain reliability of 0.95 Weakness Convenience sample and small sample size Data collected is a subset of subjects who participated in another larger study Non-experimental longitudinal study, Level IV evidence 65 pregnant women hospitalized for antepartum bed rest Findings show increase in muscle re-oxygenation times from 48 hours of delivery up to 6 weeks postpartum with antepartum bedrest Maloni et al. (2002) performed a non-experimental longitudinal study with Level IV evidence that investigated the relation of muscle metabolism (which is the amount of time for re-oxygenation of muscles) during antepartum bed rest through the postpartum period.  The study consisted of a convenience sample of 65 pregnant women recruited from antepartum inpatient units.  The sample was divided into two groups, one group of women who were prescribed antepartum bed rest and the other was not.  Measurements included the PSC (Postpartum Symptom Checklist) which focused on muscle disuse symptoms, postpartum mobility as well as measuring muscle metabolism and re-oxygenation time.  Maloni et al. found that muscle deconditioning occurs rapidly during bed rest and symptoms present 2 days after delivery through 6 weeks postpartum.  The length of time for muscle re-oxygenation was higher for patients previously on bedrest.  Reported symptom of soreness to postural weight bearing muscles were reported by the majority of the sample.  Assessment mobility results concluded that postpartum women experienced difficulty in all seven areas of walking. This combined with the muscle atrophy was our justification for the next study. A weakness is that its an older study, but information provided within the literature review gave background about muscle atrophy and results from the study gave insight to attempt to answer our research question.

8 Randomized Factorial Trial of Falls Prevention Among Older People Living in Their Own Homes (Day, Fildes, Gordon, Fitzharris, Flamer, & Lord, 2002) Randomized Control Trial with a full Factorial Design, Level II 1090 Adults age 70 and over living at home who rated their health as good to excellent Convenience Sample/Random Group Assignment Interventions: group based exercise, home hazard management, vision improvement Strengths RCT, large sample Interventions not too inconvenient on participants Weaknesses Convenience sample Day et al. sought to test the effectiveness of, and explore interactions between, three interventions to prevent falls among older people. The interventions, (exercise, vision correction, and removal of home health hazards), were delivered to eight groups defined by the presence or absence of each intervention. The study was a randomized controlled trial with a full factorial design providing Level II evidence. The sample included 1090 participants aged 70 years and over living at home who rated their health as good to excellent. The strongest effect was observed for all three interventions combined (P=0.004), significant effect (P<0.05) was observed for the combinations of interventions that involved exercise; balance measures improved significantly among the exercise group. The strengths of the study were a Randomized Control Trial, a large sample, and the interventions were not too inconvenient for participants. A weakness was the convenience sampling method. This study’s relevance to the research question lies in it’s exercise intervention. The results of the previous study by Maloni & Schneider indicate a correlation between muscle atrophy and impaired mobility postpartum; with exercise, muscle reoxygenation time was decreased postpartum allowing quicker return to ADL .

9 Strengths Weaknessess
Ground reaction forces during gait in pregnant fallers and non-fallers (McCrory et al., 2011) Quasai Experimental- level 4 41 pregnant, 40 pregnant females age 18-45 Non-experimental, restrospective, observational study Findings: No change in GRF however, control subjects walk at a faster pace Strengths Easy to conduct First step toward demonstrating causation Weaknessess No intervention No causation or correlation McCrory et al. (2011) measured and observed ground force reactions of both pregnant women and non pregnant women. Their aim was to see if there was a difference in how much force was applied to the ground when walking. The study was non-experimental, provided level four evidence (Cohort study). The participants were pregnant and non pregnant women between yo. Women were recruited using purposive sampling and placed in either the “pregnant” or “not pregnant” group based on hormone testing. The results showed that there was no difference in ground reactive forces between the two groups. But, it was found that non pregnant women walked at a faster pace of 1.47m/s compared to the second trimester group of 1.34m/s and the third trimester group of 1.29m/s. The p-value for this test was at The strengths were that the study was easy to conduct and is a first step toward demonstrating causation of pregnant falls. The weaknesses were that there was no intervention and no causation or correlation.

10 Sensori-motor function, gait patterns and falls in community-dwelling women (Lord et al., 1996)
Quasai Experimental- level 4 183 women total aged 22-99 Non-experimental, observational, prospective Findings: walking velocity was less in multiple fallers compared to non fallers Strengths Immense amount of data collected Shows a great way to measure falls without making the event happen Weaknesses Small number of faller group Not fully randomized due to convenience sample of young people Lord et al. (1996) compiled a group of 183 women ranging between the ages of and performed over 80 measurements of movement on each person. Their aim was to see if their was a correlation between sensori-motor function scores and whether these scores predicted falls in the elderly. The study was a non-experimental, observational, and prospective study with level 4 evidence (cohort study). The measurements were taken of all participants. Every two months after the testing, questionnaires were mailed to the group over the age of 65 asking about falls experienced. They then took the data of the fallers and non fallers and compared the measurements of the two groups. Although there was a difference of 0.08 in standard deviations between multiple fallers and non-fallers, the p-value was not low enough to pass as note-worthy evidence. However if the study was done again with a larger group of 65+ aged individuals, the p-value may show enough change to mark the data as valid and important. The strengths were the sheer amount of data collected from each participant and the way the study was laid out allowed some measurement of falling without undue harm to subjects. The weaknesses were a small total population and small elderly population and the inability to be fully randomized when recruiting for the younger aged of the participants.

11 Balance (perceived and actual) and preferred stance width during pregnancy (Jang, Hsiao, & Hsiao-Wecksler, 2008) Non-experimental, prospective, repeated-measures study; Level IV 15 pregnant & 15 non-pregnant women Measured perceived balance, postural sway, stance width, & falls Perceived balance degraded & AP sway increased in pregnant group, while falls decreased; wider stance width  better perception of balance Strengths Stabilogram Diffusion Analysis measurement techniques Use of control challenges previous findings Weaknesses Loss of 3 study subjects Small convenience sample Lack of an intervention Jang et al, (2008) conducted a prospective, repeated-measures study resulting in level IV evidence; 30 women between the ages of 25 & 38, 15 pregnant & 15 non-pregnant, were used Assessments included: perceived & actual balance (which was used to justify the next study) were assessed every 4 weeks during pregnancy, & at 6, 12, & 24 weeks post-delivery; assessment included a questionnaire that asked participants to rank their balance & stability & any incidences of falls, postural sway with a large force plate, & measuring of stance width Findings include: pregnant women experienced a significant sense of balance degradation, increased sway in the anterior-posterior direction, & less falls than the control (which could be contributed to the perceived decrease in balance leading to increased care to avoid falls); also pregnant women with wider stances were generally found to have better balance perception, leading researchers to conclude that patients with a decreased perception of balance might benefit from widening their stance Strengths of the study include: better results with new stabilogram diffusion analysis measurements & the addition of a control group, which was lacking in previous studies Weaknesses include: small convenience sample, loss of 3 subjects, & lack of an intervention

12 Falls among dizzy patients in healthcare: an intervention study with control group (Hanson, Mansson, Ringsberg, & Hakansson, 2008) Strengths Research definitions: “self-perceived handicap” & “unsteadiness problems” Use of control challenges previous findings Weaknesses Non-randomized sampling Study shortened Loss of 13 subjects Quasi-experimental, non-equivalent control group; level III 58 multi-sensory dizziness patients Self-perceived handicap related to dizziness, balance, & falls Balance measures were effective in predicting falls; Vestibular rehab training was not effective Hanson et al, (2008) conducted a non-equivalent control group study yielding level III evidence; 58 patients, over the age of 65, with multi-sensory dizziness not explained by another diagnosis & over the age of 65 were included This study was used for our population based on their research definitions of “self-perceived handicap” (Hanson et al, 2008) & “unsteadiness problems” (Jacobsson & Newman 1990), which align with the perceived balance measures used in the study just discussed Assessments included: self-perceived handicap related to dizziness, balance, & falls among patients with dizziness; 4 balance measures were used, the most effective of which was tandem stance with eyes open; patients who performed poorly here had twice the fall risk of those who did not; The intervention of vestibular rehab training was found to be ineffective at reducing falls Study strengths include: the research definitions already mentioned; & the addition of a control challenging previous findings Weaknesses are: the non-randomized group assignment, the study was shortened because patients did not want to wait 12 months for treatment, & the loss of 13 subjects

13 Epidemiology of Maternal Injuries During Pregnancy in a Population-Based Study (Tinker, Reefhuis, Dellinger, & Jamieson, 2010) Non-experimental, Retrospective; Level VI 6609 mothers of infants: random sample No intervention; Instrument used was telephone interviews 51.6% injuries reported from falls. Falls more likely to be reported in the second and third trimesters Strengths Large sample Population-based study subjects from multiple states across country Diverse demographic & socioeconomic background Weaknesses Study limited by reliance on self-reported data Mothers more likely to report only injuries given in examples by the interviewer Tinker et al. (2010) sought to describe factors related to injury during pregnancy. This was a Non-experimental, Retrospective, population-based study with Level VI evidence. Telephone interviews were conducted between 6 weeks and 2 years after the birth of a healthy infant. Mothers were asked to report injuries and how they occurred. The study found that 51.6% of injuries were due to falls and that falls were more likely to be reported in the second and third trimesters. Strengths of the study include it’s large sample; and it was a population-based study with subjects from multiple states across the country, which provided subjects with diverse demographic and socioeconomic backgrounds. Weaknesses are: the study was limited by reliance on self-reported data from the mothers, and the mothers were more likely to report only those injuries that were given as examples by the interviewers.

14 Postural equilibrium during pregnancy: Decreased stability with an increased reliance on visual cues (Butler, Colon, Druzin & Rose, 2006) Non-experimental, Correlational, Level IV 12 Pregnant Women, 12 Non-pregnant Women Does not explain how sample was attained. Postural Stability Declines during pregnancy Strengths Control Group Informed Consent Study protocol was approved by Stanford Committee Weakness Small Sample Size Unknown Attained Sample Butler et al. (2006) attempted to determine whether there are changes in postural equilibrium during pregnancy and examines whether this increased the incidence of falls.  The non-experimental, correlational study provided Level IV evidence. The sample size consisted of 12 pregnant women and 12 non-pregnant women. During the second and third trimester of pregnancy the center of pressure was wider resulting in a decline in postural stability and remains diminished 6 to 8 weeks post-delivery compared to the non-pregnant women who had a narrow center of pressure. Out of the 8 women who returned for the postpartum visit, 2 women reported sustaining a fall during their 2nd and 3rd trimester. The strengths were the use of a control group, the informed consent, and the study protocol was approved by the Stanford University Human Subjects Committee. The weaknesses were the small sample size, and the authors did not provide how they attained subjects for the study.

15 Catch a Falling Star: The Development of the Obstetric Falls Risk Assessment System (Heafner, Suda, Casalenuovo, Leach, & Gawlinski, 2011) Quasi-experimental, Level III evidence Obstetric in-patients in Phase I and II. Proposed population in Phase III is 100 epiduralized obstetric patients postanesthesia Obstetric Falls Risk Assessment System, (OFRAS) Following implementation of Phase I, falls decreased from 6 to 1 in an 8 month period. Strengths Developed by a panel of expert perinatal nurses & validated through literature review. Financially feasible Weaknesses Judgment of inexperienced nurses using OFRAS may be less accurate Study still in progress; sample size of Phase I & II unknown The one study found that addresses our research questions is still ongoing. Heafner et al. (2011) saw a need for an obstetric fall risk assessment tool as there are currently only fall risk scales for geriatric and/or medical-surgical patients. This was a quasi-experimental study with Level III evidence. Phase I of the study was the development and implementation of Obstretric Fall Risk Assesment System. Falls decreased from 6 to 1 in an 8 month period. Strengths were that the fall risk factors for the OFRAS were determined by a panel of expert perinatal nurses and were validated through literature review and that the study was financially feasible. Weaknesses of this study are judgment of inexperienced nurses using OFRAS may be less accurate than that of experienced nurses, and expansion of the study to other sites has not yet happened so the sample size may be too small to make any conclusions.

16 Summary of Evidence Falls in the perinatal population are preventable. Anticipatory guidance with patient teaching would be effective at reducing incidences of falls (Dunning, et. al, 2009) Antepartum or at home bed rest duration information may be an assessment criteria to review upon receiving a postpartum patient to reduce the risk for falls (Maloni & Park, 2005) Patients with a decreased perception of balance might benefit from widening their stance (Jang, Hsiao, & Hsiao-Wecksler, 2008) Tandem stance with eyes open most effective at predicting fall risk. (Hanson, Mansson, Ringsberg, & Hakansson, 2008) Falls in the perinatal population are preventable. Anticipatory guidance with patient teaching would be effective at reducing incidences of falls (Dunning, et. al, 2009) Antepartum bed rest duration information may be an assessment criteria to review upon receiving a postpartum patient to reduce the risk for falls (Maloni & Park, 2005) Pregnant women experience a significant sense of balance degradation, and increased sway in the anterior-posterior direction. Patients with a decreased perception of balance might benefit from widening their stance (Jang, Hsiao, & Hsiao-Wecksler, 2008) Tandem stance with eyes open most effective at predicting fall risk. Fall risk is doubled for patients who perform poorly in this stance (Hanson, Mansson, Ringsberg, & Hakansson, 2008)

17 Summary of Evidence 51.6% of all injuries reported during pregnancy were from falls. Falls more likely to be reported in the second and third trimesters (Tinker et al., 2010) Improved balance observed for combinations of interventions that involve exercise (Day et. al., 2002) During the second and third trimester of pregnancy the center of pressure is wider resulting in a decline in postural stability (Butler, Colon, Druzin & Rose, 2006) Evidence shows implementation of a fall risk tool specifically for pregnant women will decrease falls (Heafner, et. al., 2011) 51.6% of all injuries reported during pregnancy were from falls. Falls more likely to be reported in the second and third trimesters Significant effect, (P<0.05), of improved balance observed for combinations of interventions that involved exercise. Balance measures improved significantly among the exercise group (Day et. al., 2002) During the second and third trimester of pregnancy the center of pressure is wider resulting in a decline in postural stability compared to the non-pregnant women who had a narrow center of pressure. Postural stability remains diminished 6 to 8 weeks post-delivery (Butler, Colon, Druzin & Rose, 2006) Following implementation of OFRAS tool, (fall risk tool specifically for pregnant women), falls decreased from 6 to 1 in an 8 month period (Heafner, et. al., 2011)

18 Implementation/Evaluation
Searching the literature failed to provide enough evidence to answer the question of the best way to assess falls in the perinatal setting Due to lack of evidence addressing our research question, we are unable to recommend any techniques or tools Searching the literature failed to provide enough evidence to answer the question of the best way to assess falls in the perinatal setting Due to lack of evidence addressing our research question, we are unable to recommend any techniques or tools

19 Results Evidence is inconclusive and does not answer the research question There is a need for an assessment tool specific to pregnant women Research on fall risk assessment in perinatal patients is justified Higher level research is needed to answer this question The evidence is inconclusive and does not answer the research question There is a need for an assessment tools specific to pregnant women Research on fall risk assessment in perinatal patients is justified Higher level research is needed to answer this question

20 Suggestion for Future Research
Based on lack of evidence: development of assessment tools controlled trials Meta analysis to accurately determine the best assessment techniques Based on the lack of available research evidence, we recommend development of fall risk assessment tools for perinatal patients & controlled trials examining those tools After enough evidence is gathered on assessment tools and techniques, meta analysis should be performed on the controlled trials to better answer our question of what the best way to assess fall risk on perinatal units would be

21 References Butler, E., Colon, I., Druzin, M., Rose, J. (2006). Postural equilibrium during pregnancy: Decreased stability with an increased reliance on visual cues.  American Journal of Obstetrics and Gynecology, 195, 1104 – 1108.  doi: /j.ajog Day , L., Fildes, B., Gordon, I., Fitzharris, M., Flamer, H., & Lord, S. (2002). Randomized factorial trial of falls prevention among older people living in their own homes. BMJ: British Medical Journal, 325(7356), Dunning, K., LeMasters, G., & Bhattacharya, A. (2009, August 13). A major public health issue: The high incidence of falls during pregnancy. Maternal Child Health Journal , 14, /s Hanson E, Månsson N, Ringsberg K, Håkansson A. falls among dizzy patients in primary healthcare: an intervention study with control group. International Journal Of Rehabilitation Research, 31(1):51-57.

22 References Heafner, L., Suda, D. E., Casalenuovo, N. M., Leach, L., & Gawlinski, A. (2011). 'Catch a falling star': The development of the obstetric falls risk. doi: /j _10.x Jang, J., Hsiao, K., Hsiao-Wecksler, E. (May 2008). Balance (perceived and actual) and preferred stance width during pregnancy. Clinical Biomechanics, 23(4): Lord, S., Lloyd, D., & Li, S. (1996). Sensori-motor function, gait patterns and falls in community-dwelling women. Age and Ageing, (25), Maloni, J. A., & St. Pierre Schneider, B. (2002, May ). Inactivity: Symptoms associated with gastrocnemius muscle disuse during pregnancy. AACN Clinical Issues, 13(2),

23 References Maloni, J. A., & Park, S. (2005). Postpartum symptoms after antepartum bed rest. Journal of Obstetric, Gynecology and Neonatal Nursing Clinical Research, 34, McCrory, J., Chambers, A., Daftary, A., & Redfern, M. (2011). Ground reaction forces during gait in pregnant fallers and non-fallers. Gait & Posture, 34, Tinker, S. C., Reefhuis, J., Dellinger, A., & Jamieson, D. (2010). Epidemiology of maternal injuries during pregnancy in a population-based study, 1997– Journal Of Women’s Health, 19(12), doi: =jwh


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