Midwives’ and registered nurses’ role and scope of practice in acute early pregnancy care services: a scoping review

Nicole Freeman; Jane Warland; Kate Cheney; Zoe Bradfield

doi:10.11124/JBIES-23-00483

. 2024 May 21;22(10):2090–2129. doi: 10.11124/JBIES-23-00483

Midwives’ and registered nurses’ role and scope of practice in acute early pregnancy care services: a scoping review

Nicole Freeman ^1,^2,^✉, Jane Warland ³, Kate Cheney ^1,⁴, Zoe Bradfield ^1,³

PMCID: PMC11462904 PMID: 38769931

Abstract

Objective:

The objective of this scoping review was to investigate and describe what is reported on the role and scope of practice of midwives and registered nurses providing care for women with pregnancy complications prior to 20 weeks’ gestation in acute clinical settings in Australia.

Introduction:

In many high-income countries, women experiencing unexpected complications in early pregnancy attend an acute care service, such as an emergency department, rather than a maternity or obstetric unit. This service structure can impact the care women receive and determine who provides it. Women and their partners, who are often experiencing emotional distress, have reported difficult experiences when accessing acute services, particularly emergency departments, which are not traditionally staffed by midwives. The role and scope of practice of both midwives and registered nurses providing acute early pregnancy care in most high-income countries, including Australia, is poorly reported. Documenting this area of practice is an important first step in facilitating ongoing research in this important aspect of pregnancy care.

Inclusion criteria:

Published and gray literature that described the role and scope of practice of midwives and/or registered nurses providing care in acute early pregnancy settings in Australia were considered for this review.

Methods:

A scoping review of the literature was conducted following JBI methodological guidance and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A 3-step search strategy was conducted to explore evidence from databases and search engines, gray literature sources, and selected reference lists. The search was limited to sources published from 2005 until October 2023. The databases searched included MEDLINE (Ovid), MIDIRS (Ovid), JBI Evidence-based Practice Database (Ovid), CINAHL Ultimate (EBSCOhost), ProQuest Central, Web of Science Core Collection, Scopus, and Cochrane Library. Google and Google Scholar were also used to identify published studies. After screening, data were extracted from records selected for the final review, mapped, and analyzed using content analysis.

Results:

A total of 23 sources were selected for inclusion in the review, and these included primary research studies, conference abstracts, and gray literature, such as clinical guidance documents, academic theses, and websites, from January 2008 to October 2023. The most common setting for care provision was the emergency department. Midwives’ and registered nurses’ role and scope of practice in acute early pregnancy care in Australia can be categorized into 4 areas: physical care, psychosocial support, care coordination, and communication. Women’s access to midwifery care at this time in pregnancy appears to be limited. Registered nurses, usually employed in emergency departments, have the most prominent role and scope in the provision of care for women with acute early pregnancy complications. Descriptions of midwives’ practice focus more on psychosocial support and follow-up care, particularly in early pregnancy assessment service models.

Conclusions:

This review highlights the inconsistency in midwives’ and registered nurses’ role and scope in acute early pregnancy in Australia, a finding which is relevant to other international settings. Both professions could further fulfill role and scope capacity in the provision of supportive, individualized, and timely care for women and families accessing a range of acute early pregnancy services. Emergency departments are the usual practice domain of registered nurses who may be limited in terms of the scope of care they can provide to women with early pregnancy complications. Leaders of the midwifery profession should conduct further research into innovative service models that embed a role for midwives in all settings that provide care for pregnant women, regardless of stage of pregnancy.

Review registration:

Open Science Framework https://osf.io/7zchu/

Keywords: early pregnancy complications, emergency care, job description, midwifery practice, nursing practice

Introduction

Unexpected complications can occur at any point during pregnancy. In early pregnancy (prior to 20 weeks’ gestation), the most common reason for an unscheduled visit to an acute health service is vaginal bleeding and/or pain.^1–6 Other conditions include nausea and vomiting of pregnancy, hyperemesis gravidarum, ectopic pregnancy, and miscarriage.^6–8 Presentation to acute care services can be a time of significant physical discomfort, psychological distress, and uncertainty for women, partners, and their families.^9,10 We acknowledge that not every pregnant person identifies as a woman, although we use the terms woman and women in this review to describe any person who is pregnant, including those who do not identify as female.

While choice and access to early pregnancy services in Australia is affected by factors such as geographical location and health insurance status,^11,12 most women accessing acute hospital care for unexpected pregnancy problems before 20 weeks’ gestation are directed to an emergency department (ED) rather than a maternity unit or obstetric service.^6,8,13 The division of acute early pregnancy care services determines who cares for the woman, with EDs usually staffed by registered nurses (RNs), emergency doctors, and on-call gynecology doctors. Midwives are mostly employed in maternity units caring for women from 20 weeks’ gestation.^14,15

While this review focuses on the Australian health care context, it is important to acknowledge that this division of acute health care provision in early pregnancy also occurs in other countries.^3,10,16 The experiences of women and partners attending an ED setting with acute early pregnancy concerns is well documented in Australia and internationally.^4,9,13,17,18 Consistent themes have been identified in the literature regarding the shortcomings of the ED environment, particularly for women experiencing symptoms of early pregnancy loss. The lack of informative communication, emotionally supportive care, and follow-up from health care providers contribute to the difficult experiences many women and partners report in this setting.^3,9,16–18 An ED can be a chaotic environment with busy staff who may lack the time and specialist skills to best support women who may be highly anxious about their own well-being and that of their pregnancy.^3,13,18 Women may be bleeding, have pain, or be emotionally distressed, and require a level of acknowledgment and information from health care providers of the physical and emotional significance of the presentation from the woman’s perspective.^3,13,18 As many women presenting with symptoms such as vaginal bleeding are hemodynamically stable, they may be triaged as a lower priority than other presentations,¹² enduring long wait times in busy waiting rooms lacking privacy.^9,13,16

The early pregnancy assessment service (EPAS) or unit model, initially trialed in the United Kingdom (UK), aimed to divert care away from general EDs into more appropriate and specialized settings.^19,20 The concept has been adapted into a variety of acute early pregnancy models (referred to as EPAS for this review) in Australia and internationally.^19,21–25 Some models are embedded within an ED⁶ or run as outpatient services.^25,26 Although still subject to challenges around access, waiting times, and physical location,^23,27 evaluation of EPAS models has generally been positive in terms of women’s experiences, clinical outcomes, and economic viability.^6,22 These models, like ED settings, are often staffed by RNs.^25,27 In the UK, where midwives work across a range of clinical settings providing continuity of care for women with complications and additional needs, it is still common for specialist RNs, rather than midwives, to be employed in EPAS models.^23,28–30

It is internationally recognized that midwives have the educational preparation and clinical expertise to care for women throughout pregnancy.^31,32 Routine antenatal care, often initiated before 20 weeks, is the practice domain of midwives in Australia.³³ However, women under 20 weeks’ gestation with acute complications are not routinely cared for in units staffed by midwives. Even when antenatal care has been initiated by a midwife, women who subsequently experience complications, such as pain or bleeding, before 20 weeks are often referred to an acute care setting staffed by RNs.²⁷ With the national interest in acute early pregnancy care provision, particularly in relation to early pregnancy loss,³⁴ exploring innovative practice models that facilitate midwives to be “with women” throughout pregnancy are essential.

An exploration of the role and scope of practice of both midwives and RNs who work in acute and subacute settings caring for women with early pregnancy complications in Australia has not been previously explored in the literature. It is important to document this under-reported area of pregnancy care and the place that midwives and RNs occupy within it. The emotional well-being of women and partners, particularly those experiencing potentially traumatizing experiences such as miscarriage, can be significantly influenced by the quality of their interactions with health professionals.^3,9,22,35 Exploring what is reported about midwives and RNs working in acute early pregnancy settings in Australia is a crucial first step in examining this important area of pregnancy care, and this was the overarching objective of this review.

As role and scope of practice may be described in documents such as clinical guidelines, professional standards, opinion pieces, and published studies, a scoping review was identified to be the most appropriate method of evidence synthesis for this review. Scoping reviews assist in clarifying concepts, identifying knowledge gaps, and assessing the value of undertaking further research.³⁶ The primary intention of a scoping review is to map and summarize the relevant evidence on a particular phenomenon of interest,³⁷ enabling an exploration of a variety of evidence. This is particularly useful for summarizing topics that may be relatively unexplored, niche, or emerging.³⁸ While the methodology does not typically involve critical appraisal of the quality of included evidence,³⁷ it still requires thoughtful interpretation of results and informed discussion regarding the relevance to the review objectives and future research.^36,39–41

An initial search of MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted prior to this review commencing. No current or in-progress systematic or scoping reviews on the topic of interest were identified. This review had 3 overarching objectives: i) to investigate and describe the role and scope of practice of midwives and RNs providing acute early pregnancy care in Australia; ii) to investigate and describe the clinical settings that midwives and RNs provide acute early pregnancy care in Australia; and iii) to develop a concept map that illustrates the characteristics of key elements of midwives’ and RNs’ practice in a range of acute early pregnancy care settings in Australia.

Review question

What is the role and scope of practice of midwives and RNs providing care for women with pregnancy complications prior to 20 weeks’ gestation in acute care settings in Australia?

Inclusion criteria

Participants

Sources of evidence describing the role and scope of midwives and RNs were included in the review, as in Australia both professions provide acute early pregnancy care.^4,42 Evidence describing nurse practitioners (NPs) was also included, as NPs are RNs with additional academic, practice, and regulatory capacity often employed in acute settings such as EDs.^6,12,43,44 Student midwives, student nurses, enrolled nurses, assistants in nursing, Indigenous health workers, allied health professionals (including sonographers), and medical doctors were not included, as the role and scope of practice of these practitioners were not the focus of the review.

Concept

Sources of evidence that describe the role and scope of practice of midwives and/or RNs providing care for pregnant women prior to 20 weeks’ gestation in acute early pregnancy settings in Australia were considered for the review.

Context

Variations exist between countries in terms of the professional nomenclature, regulation, and registration of midwives and RNs, as well as the structure and function of international health care systems.^7,24,25 To ensure homogeneity within the capacity and scope of this review, only publications describing early pregnancy care in Australia were considered. The terms midwife, registered nurse, and nurse practitioner have protected title status in Australia and are regulated at a national level,^43,45–47 meaning that their use in evidence relating to the Australian context is consistent. The definition of early pregnancy for this review was prior to 20 weeks’ gestation, which reflects the legal distinction between miscarriage (<20 weeks) and perinatal (stillbirth and neonatal) deaths (≥20 weeks) in Australia.^48,49 This definition aligns with the usual terminology in Australian health care literature.^11,50

Acute health care settings where women present for unscheduled assessment of early pregnancy concerns (eg, an ED) were considered for inclusion in the review. The subacute setting of an EPAS model was also included under the description of acute in this review. These services provide an alternative referral source for assessment and follow-up of early pregnancy problems.^19,23,51 Unscheduled visits to a primary care midwife or RN in a community setting were also considered. Presentations in early pregnancy to any of these settings where the primary presenting problem was not pregnancy related (eg, trauma, respiratory illness, accidental injuries) were not included.

Although women with early pregnancy symptoms may first present to their general practitioner (GP),⁵² unscheduled visits to GPs in community practices were excluded, as the role of medical doctors was outside the scope of this review. Scheduled antenatal appointments in community or hospital settings (with midwives, RNs, or medical doctors) were also not included, as these presentations are not acute or subacute in nature.

Types of sources

Sources considered relevant for this review included published evidence (eg, primary qualitative, quantitative, and mixed method studies and evidence synthesis reviews) and gray literature (eg, narratives, opinion/discussion pieces, websites, clinical guidelines, professional standards, academic theses).

Publications dated from 2005 onward were included, as this aligns with the establishment of the first EPAS models in Australia.^19,51 When reviewing evidence, the authors were mindful of the shift in 2010 to nationwide regulation and registration of all health practitioners, including midwives and RNs, in Australia.⁴⁵ Records prior to this date that describe the midwifery or nursing role and scope would reflect individual state or territory, rather than national, guidance or practices. As the search was restricted to the Australian context, only publications available in English were considered.

Methods

This scoping review follows current methodological guidance from JBI^53–55 and is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).^40,56 An a priori protocol was registered with Open Science Framework (https://osf.io/7zchu/) and published in JBI Evidence Synthesis in April 2023.⁵⁷

Search strategy

A 3-step search strategy³⁷ was undertaken by NF in collaboration with a faculty librarian. An initial search was conducted in databases MEDLINE (Ovid) and ProQuest Central (Clarivate) for evidence relevant to the review topic. A comprehensive matrix of key words, phrases, and combinations of these were trialed in the development of a concept grid and full electronic database search strategy for MEDLINE and ProQuest. This was adapted to suit other databases, search engines, and gray literature sources.

Following consultation with the research team, the second step involved a full search of all relevant information sources. Finally, reference lists of sources selection for inclusion in the review were searched for relevant citations. All electronic database sources were initially searched on August 29, 2022. Published data from search engines were considered until October 17, 2022, and gray literature sources to November 12, 2022. To account for some unavoidable delays between search and synthesis, a full second search for evidence updates from all data sources was conducted between October 9 and 11, 2023, ensuring a thorough, contemporary review. A new EndNote v20.1 (Clarivate Analytics, PA, USA) library was opened and a modified EndNote automated deduplication method⁵⁸ was used alongside manual checking to identify new records for screening. To ensure the accurate capture of additional data, new records identified from records dated after the first search dates were cross-checked against every record identified in the full search rerun (minus duplicates) in the new EndNote library. Search results for all databases and gray literature are provided in Appendix I.

The databases searched were MEDLINE (Ovid), MIDIRS (Ovid), JBI Evidence-based Practice Database (Ovid), CINAHL Ultimate (EBSCOhost), ProQuest Central, Web of Science Core Collection, Scopus, and Cochrane Library. Searches included words found in whole documents. If search results were too large to be manageable, further topic or subject limits were applied. The online search engines Google and Google Scholar were also used to identify published studies by applying simplified search strings related to the full database search strategy. Records retrieved from all sources were managed in a newly created EndNote library.⁵⁹

Search terms were modified from the database search strategies to capture the most appropriate gray literature results using adapted search strings in Google, Google Scholar, and ProQuest Dissertations and Theses. For feasibility purposes, title and abstract screening of the first 10 pages of records was initially conducted by NF. Records identified as potentially meeting the review criteria at title and abstract screening were imported into EndNote. Due to time constraints, reference list and citation searching was conducted only from reports included in the final review.³⁷ All potentially eligible gray literature and reference/citation records were imported into EndNote.

Duplicates were removed through EndNote software automation and manual checking. The final group of records identified through all search strategies were exported from EndNote into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).^60,61

Study selection

All records were screened in JBI SUMARI at title and abstract and full text by at least 2 reviewers using the inclusion criteria and highlighted keywords relevant to the review question and objectives. Pilot title and abstract screening of the first 100 records was conducted by all 4 review authors, with notes made under individual record details if required. Conflicts (after screening by 2 reviewers) were managed by a third reviewer, assisted by any notes others had made in JBI SUMARI. Records retrieved from search engines, gray literature, reference lists, and citation searching required preliminary screening by NF prior to being considered for inclusion and imported into EndNote. These were subsequently screened at title and abstract in JBI SUMARI by 2 other reviewers.

The final group of unique records from all searches eligible for title and abstract screening (n=941) were exported from EndNote into JBI SUMARI.⁶⁰ A total of 861 records were excluded at title and abstract screening based on the exclusion criteria for the review. The remaining 80 records went through to full-text screening with 23 selected for inclusion in the final scoping review. A detailed list of all records excluded at full-text review (n=57) is attached as Appendix II. Results from the initial and second searches of all data sources were merged and are presented in a PRISMA flow diagram.⁶²

Data extraction

Data extraction was completed for all included full-text records using evidence-specific data extraction tools in JBI SUMARI.⁶¹ Pilot testing of different types of included records was initially conducted by 2 reviewers, with exported data extraction tables generated by the software revised and modified as data extraction continued.^37,54 This iterative process involved review authors meeting to revisit and adjust extraction metrics, ensuring that retrieved data aligned with the research question and objectives.^39,53 Any disagreements regarding eligible data were resolved by discussion.⁴⁰

Data extracted from all sources included author/s, year of publication, type of evidence, methodology (if applicable), phenomena of interest, setting/context, and participants/sample characteristics. JBI SUMARI adjusted the default data extraction table metrics to suit each type of evidence under review. A detailed multitable version of the full-text data extraction template, with adjustments to suit individual evidence types, is provided in Appendix III.

Data analysis and presentation

Simple coding and categorization of data extracted from included records was conducted to clarify definitions and to illustrate and describe the key characteristics of review findings.⁵⁵ A basic qualitative content analysis technique involving a complete read through of data, highlighting of key words and phrases, and clustering of similar concepts into larger categories was used to organize extracted data. This is an acceptable approach for managing and summarizing data in a scoping review, and can be used on any sources of evidence, not just qualitative studies.⁶³

Critical appraisal

The purpose of a scoping review is to map the available evidence and present it in a visual and narrative summary format. While critical appraisal of the quality of included records is not required for a scoping review, thoughtful reflection on the characteristics of the review findings enables identification of gaps in the evidence, which may benefit from further evidence synthesis or research.³⁷

Results

Source of evidence inclusion

The database search identified 1279 records, of which 378 were excluded before screening. The final group of unique records from all searches eligible for title and abstract screening (n=941) was exported from EndNote into JBI SUMARI.⁶⁰ A total of 861 records were excluded at title and abstract screening for not meeting the inclusion criteria for the review. The remaining 80 records went through to full-text screening, with 23 selected for inclusion in the final scoping review.^{14,35,42,64–83} A list of all records excluded at full-text review (n=57), with reasons for exclusion, is provided in Appendix II. Results from the initial and second searches of all database sources were merged and are presented in a PRISMA flow diagram (Figure 1).⁶²

Search results and source of evidence selection and inclusion process⁶²

Characteristics of included sources

The sources included in this review (n=23) consisted of primary research studies (n=11), conference abstracts (n=2), evidence synthesis reviews (n=2), academic theses (n=2), clinical updates or guidelines (n=3), and a single website, news report, and opinion piece. Of the primary studies and theses, the majority were qualitative in nature (n=9), in addition to cohort studies (n=4). The master of philosophy (MPhil) thesis⁶⁴ led to a primary research publication also included in this review.³⁵ Cheney and Pelosi⁴² share authorship of a conference abstract and primary research study⁶⁵ in the review, both of which describe elements of the same clinical implementation project in Sydney. Trostian^66,67 is first author of an integrative review and a cohort study describing different perspectives of early pregnancy bleeding presentations in the ED, both of which are included in this review.

Qualitative studies included individual in-depth interviews and analysis of narrative data.^{14,35,64,68–73} Four of these studies used qualitative description methodology for data analysis.^35,64,70,73 There was 1 grounded theory study⁶⁹ and a PhD thesis guided by action research methodology.¹⁴ The MPhil thesis⁶⁴ described a mixed methods study that included data from audit and field notes, but was primarily qualitative in nature. There were 4 cohort studies: 2 that examined outcomes from an EPAS model project with an NP⁷⁴ or consultant midwife⁶⁵ providing specialist care to women in an ED, 1 that evaluated a point-of-care ultrasound course for rural clinicians,⁷⁵ and 1 that examined ED presentation data related to women with bleeding in early pregnancy.⁶⁷

The evidence syntheses^66,76 reviewed different aspects of acute early pregnancy care. Stratton and Lloyd⁷⁶ explored the availability of psychosocial support services at and following miscarriage. Their review did not specify a particular evidence synthesis methodology. The more recent publication by Trostian et al. ⁶⁶ explored several aspects of ED presentations involving women with vaginal bleeding in early pregnancy and applied a more contemporary integrative review methodology. The remaining sources (n=3) focused on aspects of clinical care provision for women with miscarriage⁷⁷ or hyperemesis gravidarum.^78,79 One source was an opinion piece detailing personal experiences of miscarriage that described a midwife’s role in bereavement support.⁸⁰ Two sources (1 website and 1 online news article) described an online midwifery assessment service for women with acute early pregnancy and gynecological problems in South Australia.^81,82

Review findings

Population, participants, target audience

All included sources described the care of pregnant women prior to 20 weeks’ gestation with early pregnancy complications and were of relevance to health professionals providing a range of acute early pregnancy care services. Midwives and/or RNs were participants in 8 of the 11 primary research studies.^{14,35,64,68–71,75} Women with early pregnancy complications were interview participants in 5 studies.^{14,68,69,72,73} One study also explored partners’ perspectives.⁶⁹

Context

All sources were set in the Australian health care context. The evidence synthesis reviews^66,76 included both Australian and international literature but were considered appropriate for inclusion as they were authored by Australian researchers and included Australian evidence that is relevant and applicable to the review question and local context. Five sources reviewed by Trostian et al. ⁶⁶ were also included in this review.^{65,68,69,72,74} The setting for just over half the sources (n=12) was an ED, with many of these also having some version of an EPAS in the ED or nearby (n=7). One study described a 24/7 early pregnancy assessment protocol, a care pathway that could be used by ED clinicians to care for women when the nurse-led early pregnancy clinic was closed.⁷⁴ Two sources focused exclusively on care provided to women in an EPAS setting.^35,64

All sources included descriptions of early pregnancy problems requiring acute care or assessment prior to 20 weeks’ gestation. Although not all women who attend acute early pregnancy services will be having a miscarriage,⁷² most sources included in this review focused on presentations related to threatened or confirmed early pregnancy loss (n=19). The terms miscarriage ^{69,71,73,74,76,77,83} and early pregnancy loss,^{35,42,64,70,81,82} often the sequelae of vaginal bleeding,^66,67 were the most cited complications of early pregnancy in this review. The emergency presentation and care of women with hyperemesis gravidarum were described in 2 sources.^78,79

Concept

All sources described some aspect of midwifery or nursing role and/or scope of practice in acute early pregnancy care in Australia. Most sources referred to midwives and/or RNs as part of a larger multidisciplinary group,^{14,35,64,66–68,71–77,80,82} or in more distinct independent roles.^{42,65,74,78,79,81,83} One study explored ED nurses’ practice as part of a wider exploration of women’s and partners’ experiences.⁶⁹ Another focused primarily on RNs, some of whom happened to also be midwives.⁷⁰ Three sources^77,79,83 provided direct guidance or education regarding clinical midwifery or nursing care of women with early pregnancy complications. Many of the sources referred primarily to RNs (including ED nurses and NPs), with only 5 sources specifically describing midwives providing primary care before 20 weeks’ gestation.^{42,65,77,81,82}

Key findings identified from the data

The data mapping process resulted in the identification of 4 interconnected elements of midwifery or nursing roles and scope in the acute early pregnancy setting in Australia. These are described in more detail below and summarized as a concept map in Figure 2.

Concept map of key elements of midwives’ and registered nurses’ role and scope of practice in acute early pregnancy care in Australia

Physical care a priority

The physical care RNs and midwives provide to women with acute early pregnancy concerns was a prominent feature of the review data, with just over half of the included sources informing this category.^{14,66,67,69,71,72,74,75,77,79,81,83} Prioritizing physical care needs is particularly common at the front line of acute care services. RNs who work in the ED have a prominent role in the triage, assessment, and treatment of women presenting with early pregnancy concerns in Australia.^{14,67–69,72,74,79,83} Focusing primarily on the assessment of physical well-being at initial presentation is not an unexpected finding considering that acute early pregnancy symptoms, such as bleeding, pain, or severe vomiting, can lead to rapid clinical deterioration if not treated promptly.^{68–70,77,83} A comprehensive initial assessment of women may, however, be hindered by the lack of privacy at triage and in waiting rooms of ED settings.⁷²

The scope of practice of midwives and RNs varied and depended on qualifications and experience, individual service contexts (geographical and operational), time constraints, and individual staff’s perception of their professional responsibilities.^35,68 Most RNs in ED settings perform triage assessment (including brief history; assessment of symptoms, such as bleeding; observations; and pain score), initiate treatment in collaboration with medical colleagues,^69,74 and facilitate investigations, such as ultrasound.⁶⁸ The specialist midwifery and nursing roles (ie, clinical midwifery consultant and NP) involve more significant scope in terms of application of advanced clinical skills, independent decision-making and treatment, and staff education.^{42,67,74,78,79,83}

NPs have advanced knowledge and an expanding scope of practice in ED settings.⁶⁷ NP practice parameters relevant in early pregnancy care can extend to diagnosing, ordering investigations, interpreting results, prescribing and administrating medications and intravenous fluids, providing nutritional support (enteral or parenteral feeding, the use of acupressure for nausea), organizing surgical procedures, and assessing need for hospital admission.^68,74,79,83 Some NPs may also have additional training specific to early pregnancy, enabling them to perform and/or interpret early pregnancy ultrasound, conduct speculum and vaginal examinations, prescribe and administer Anti-D immunoglobulin injections, and provide preconception counseling for subsequent pregnancies.^68,83

The midwives’ scope within an ED environment—to provide direct clinical care, reduce length of stay, and educate and support RNs caring for women in early pregnancy—has been acknowledged by some authors.^14,42,65,74 The Virtual Pregnancy Assessment Service described in South Australia^81,82 identifies midwives as the health care professionals with the experience and capacity to triage, advise, and organize care for women with physical symptoms related to early pregnancy. The identification of midwives as the most appropriate professionals to provide this virtual care to non-pregnant women with acute gynecological concerns is unique to the 2 sources describing this Australia-first initiative.^81,82

Leaders in psychosocial support

Women and partners experiencing complications in early pregnancy require a high level of emotional and social support from care providers.⁷¹ Edwards et al. ⁶⁹ described women and partners as “hyperaware”^(p.299) of staff attitudes and willingness to give equal priority to physical and emotional needs in acute early pregnancy settings. Midwives and RNs were identified consistently in all records as members of the health care team who are well placed to provide this support. Triage RNs in EDs should be able to recognize, acknowledge, and understand women’s emotional needs in a sensitive and supportive way when they first present for care.¹⁴ Although often discussed in the context of early pregnancy loss, both sources describing hyperemesis gravidarum presentations to EDs emphasized the importance of NPs conducting mental health assessments and providing psychosocial support.^78,79

Griffin et al. ⁷⁰ described the important capacity of RNs to perform “emotion work,” in which they “gift” their managed emotions to women suffering emotional distress in relation to early pregnancy complications. Key elements of the emotion work concept have also been identified as important aspects of psychosocial support that midwives or RNs provide in acute early pregnancy settings. These include counseling, listening, and acknowledging the significance of the presenting problem; involving and caring for partners/families; addressing and mitigating guilt; providing a safe private space; and offering physical presence and/or touch.^{35,64,66,72,73,76,77,79,80,83} Other elements reported by some authors included the use of sensitive/appropriate language,^14,35,64,73 an empathetic approach,⁶⁹ and, where possible, facilitating memory-making for pregnancy loss.^35,64,73

Midwives have been identified as health professionals who are particularly well suited to provide individualized, ongoing psychosocial support and follow-up that many women experiencing early pregnancy complications require,^74,76 particularly in an EPAS model of care.^{14,35,42,64,65} A specific bereavement midwife providing support as part of a perinatal loss team is described in 1 source.⁸⁰ There is also recognition that midwives can provide emotional support for women with worrying symptoms outside of an acute care setting through a video link service model.⁸²

Individual and service coordination

Midwives and RNs working in acute early pregnancy settings have a multifaceted liaison role that goes beyond the provision of direct clinical care to women and families. This is particularly evident in the EPAS setting where women may require ongoing support over several appointments.^35,64,68,77 Their role encompasses individual case management, including providing continuity and emotional support for individual women during times of physical and/or psychosocial need, in addition to recognizing the need for multidisciplinary team (MDT) collaboration, referral, and follow-up.^{14,35,64,68,70,78,79,83} This role is also evident in the Virtual Women’s Assessment Service model,^81,82 where midwives must identify those women who require referral to other services, multidisciplinary collaboration, or face-to-face assessment. Other elements include preparing women to go home; EPAS model coordination and development; documentation, education, and emotional support for women, families, and peers^{35,64–66,68–70,72,74,76,77}; as well as leading research to investigate parents’ perspectives.^14,68,69,72

A central communication point

Midwives and RNs provide important information on all aspects of acute early pregnancy care, providing written information, explanations, and telephone advice to women and families. This may include guidance regarding pain and bleeding, nausea and vomiting, treatment options for miscarriage, future pregnancy planning, acute contraception concerns, and education regarding signs and symptoms that may require re-presentation.^{35,64,68–73,77,81–83} They are also a source of support and education for other health professionals.^42,83 Midwives were identified by some authors as possessing the unique professional preparation and specialist knowledge required to communicate information and support women’s decision-making regarding early pregnancy complications.^42,65,74,76

Communication and effective collaboration are key features of midwifery and nursing care, and this includes using appropriate and compassionate language and being reflexive and intuitive to women’s physical and psychological needs.^14,35,64,69 Recognizing the need to collaborate within the MDT forms an important aspect of role and scope in acute early pregnancy settings where women’s needs may be complex.^68,77,82 Collaboration may be with EPAS midwives or RNs, clinical midwifery consultants, NPs, medical staff, or allied health professionals including psychologists, social workers, and pastoral care practitioners.^{35,42,64,70,74,76,79,83}

Discussion

The findings from this scoping review provide novel insight into the role and scope of practice of midwives and RNs providing acute care to women in early pregnancy in Australia. Several factors have been identified that determine role and scope capacity, the nature of the care women receive, and who provides it. These include structural and organizational factors within individual services, perceived time constraints on professional practice, individual practitioners’ qualifications and experience, and the availability of multidisciplinary support.^{35,64,69,71,74,83} The role and scope of midwives and RNs in acute early pregnancy settings in Australia is varied and can include attending to women’s immediate and longer-term physical and psychological needs, consulting and liaising with the MDT, providing explanations and education, and coordinating the care of individual women and a range of early pregnancy services.

Midwives manage the care of women in acute maternity settings as part of their day-to-day role and are trained to recognize physical and psychological deterioration in the unique context of pregnancy.³² However, as most women experiencing a pregnancy complication under 20 weeks are directed to attend an ED, RNs have a particularly strong presence in literature describing acute early pregnancy care in Australia.^{68,69,72,74,78,79,83} Although this review did not aim to describe midwifery and nursing practice separately, as data were extracted, it became evident that there are some clear differences in how the role and scope of each profession is perceived and described across a range of acute early pregnancy settings. In ED settings, RNs, who have expertise in triage, assessment, and management of a wide range of presentations, provide initial care to women with a focus on urgency of physical symptoms and identification of clinical deterioration.^14,15,74 When midwifery practice was described, there was a stronger emphasis on the provision of ongoing psychosocial and follow-up support, particularly in the subacute EPAS environment.^35,42,64,65

While recognizing and attending to acute physical compromise is paramount in any health care setting, many women who present for acute care in early pregnancy are hemodynamically stable.^2,84 They may, however, be anxious, distressed, and in need of significant emotional support and accurate information for themselves and their partners.⁹ While emotional care was recognized as very important by midwives and RNs in this review,^70,83 a tendency to focus on physical needs in acute care settings means that women’s emotional state may be overlooked, unacknowledged, or misinterpreted.⁷¹ This is particularly true with the threat of early pregnancy loss, where women may be experiencing physical symptoms while simultaneously attempting to process and contextualize their feelings regarding the viability of their pregnancy.³ The prospect of waiting for long periods once triage is complete can further diminish a woman’s perception of the significance of her concerns.^14,66 It is encouraging to note that a remote access service staffed by midwives is currently available for clinically stable women in South Australia^81,82 to try to address some of the issues associated with presenting to ED settings.

Midwives’ and RNs’ practice is consistently aligned with the provision of psychosocial support in this review, which is not an unexpected finding given the strong identification of midwifery and nursing as caring, person-centric professions. It is likely that midwives and RNs, particularly in ED settings, are underutilized and undervalued in terms of their capacity to provide both timely physical care as well as individualized, informative psychosocial care³⁵ to women and their partners during what is sometimes described as an emotional, rather than physical, emergency. Despite the literature reporting that midwives and RNs describe high levels of confidence to provide counseling and support, they may have no additional education and training in this area.⁷¹ Women’s and their partners’ experiences in acute early pregnancy care settings suggest that health care professionals may not be providing adequate psychosocial support or sensitive, inclusive care.⁶⁹ Midwives and RNs should be offered educational opportunities in this area, ideally in an MDT format for all relevant staff.

There is encouraging evidence in the literature reviewed that midwives and RNs are providing more comprehensive physical and psychosocial care to women and their families in some settings. NPs, recognized to have extended scope of practice in Australia, including the capacity for specified diagnostic and prescribing rights,⁴³ report providing a significant amount of early pregnancy care in some ED settings.^67,74,78,79 Clinical midwife and clinical nurse consultant roles have also been described with varying scope.^42,65,68 NPs, specialist midwives, and RNs are interested and invested in identifying themselves as clinical leaders with advanced scope to manage acute early pregnancy care presentations, providing a breadth of service that is individualized, informative, reduces wait times, and lessens the clinical burden for other staff.^{42,65,67,68,74,78,79,83} However, endorsed midwives, who have expanded regulatory scope in Australia with prescribing and diagnostic capabilities equivalent to that of an NP,^85,86 were not mentioned in any of the literature reviewed. Consequently, the role and scope capacity endorsed midwives may have in the provision of acute early pregnancy care in Australia currently remains unknown. Further primary research is recommended to explore the function of endorsed midwives in acute early pregnancy care settings.

The advanced level of practice that an NP or clinical nurse consultant who is not a midwife may provide within an ED or EPAS setting often involves additional education, training, and supervision.^68,79,83 One evaluation of an inaugural EPAS model in an ED involved an RN (who was also identified as a midwife), and a steering committee that included 3 senior midwives.⁶⁸ Knowledge and skills that are part of normal midwifery scope in Australia are generally not part of the educational and practice preparation of RNs.⁶⁸ These may include early pregnancy physiology, vaginal examination, speculum examination, management of women with a Rhesus- negative blood group, and the use of maternal mental health assessment tools such as the Edinburgh Postnatal Depression Scale.^78,83 Despite this, it seems that midwives are often consulted to support RNs to provide care for women presenting with concerns in early pregnancy,^42,68 rather than midwives providing care for the woman directly.

Midwives have recognized expertise in sexual and reproductive health, and a strong professional focus on continuity of care and partnering with women seeking maternity care.³¹ These established roles are starkly contrasted with the lack of clear and consistent descriptions of the midwifery role and scope in acute early pregnancy care provision highlighted in this review. This is likely to be of great interest to clinicians, leaders, and researchers within the profession of midwifery. Further research is warranted to specifically explore the role and scope of practice of midwives in acute early pregnancy care. It is also hoped that data from models such as the virtual video link program being trialed in South Australia^81,82 will be collected and analyzed to provide information on the effectiveness of this type of midwifery-led service for women with early pregnancy concerns.

The capacity for midwives or RNs to order and interpret certain tests and perform skills, such as pelvic ultrasound in early pregnancy, is worthy of further discussion and exploration.^68,83 The emotional distress and uncertainty many women experience when faced with the possibility of early pregnancy loss, exacerbated by extended waiting times for investigations such as an ultrasound, can be significant.^3,27 Webster-Bain⁸³ described an NP in an ED setting in Melbourne being educated and supported to order, perform, and interpret early pregnancy investigations, including pelvic ultrasound. Midwives and RNs who have an advanced scope can help reduce waiting times, and provide women and partners with more timely information, explanations, and counseling regarding their pregnancy or symptoms.^7,25,30

It is encouraging that rural and remote RNs and midwives were invited to be part of a multidisciplinary education program to learn point-of-care ultrasound, which could be used in clinical settings that would otherwise have no access to trained sonography staff.⁷⁵ While not designed to replace the formal scanning of imaging professionals, improving access to point-of-care ultrasound training programs for rural and remote clinicians, including RNs and midwives, is a positive step toward addressing health access inequities faced by women and health care professionals living in non-urban communities. This program could also be considered for non-rural clinicians, given that access to early pregnancy ultrasound is often still limited in some urban settings.

Strengths and limitations

This scoping review offers an important knowledge synthesis from a variety of sources and has produced diverse data on the role and scope of midwives and RNs working in acute early pregnancy care in Australia that might have been excluded in other evidence synthesis methods, including 2 academic theses from Australian research students.^14,64 Given the niche area of clinical practice being explored and the potential for limited relevant data related to the midwifery role and scope in particular, a scoping review methodology enabled the authors to examine a breadth of evidence and still provide significant depth of description of the included records.

The review was limited to the Australian context. Differences in other countries in terms of the professional nomenclature and regulation of midwives and nurses, health care service structure and function, and definitions of the term early pregnancy, make it challenging to explore the role and scope outside of Australia in an homogeneous way. However, it is likely that midwives and nurses in other countries with similar health care systems, access to primary maternity care, and professional midwifery and nursing regulation will find the review useful and broadly applicable to their local context.

Conclusions

This review provides novel insight into the practice of midwives and RNs in acute early pregnancy settings in Australia, describing the important work both professions do while also highlighting areas for improvement and service innovation. In Australia, RNs have a prominent role in acute early pregnancy care provision, reflecting the organizational structure of acute services that center around EDs and gynecology settings. Midwives’ role and scope of practice in acute early pregnancy care services is less defined, highlighting the need for further research that explores midwives’ practice in the Australian context.

Implications for research

It is clear from the evidence, both in Australia and internationally, that women and their partners continue to report difficult experiences in a range of acute early pregnancy care settings. Findings from this review contribute to a better understanding of the care that midwives and RNs in Australia are providing at this important time of pregnancy, enabling benchmarking of current role and scope for both professions. A lack of clarity in the review evidence regarding midwives’ role and scope in acute early pregnancy settings highlights the need for further investigation of midwifery practice in particular. Once this is more clearly understood, research that partners with consumers and health service providers will be essential to identify future service models that meet consumer expectations and maximize professional midwifery capacity in this incredibly important area of pregnancy care provision.

Implications for practice

We found evidence in this review describing the role and scope of RNs and NPs in the ED in the provision of acute care to women with early pregnancy concerns. This was not surprising given their physical presence in the ED setting. As midwives are usually not employed in these settings, we found descriptions of midwives’ role and scope in the acute early pregnancy setting less consistent, despite midwives’ clinical expertise in pregnancy, pregnancy complications, and the provision of psychosocial support being recognized and valued in the review evidence. Practice innovation arising from this work suggests that within acute early pregnancy settings, the role that midwives could have in providing full scope sexual and reproductive health care, including acute early pregnancy care, is worthy of consideration.

Acknowledgments

Vanessa Varis, faculty librarian, Curtin University, for her assistance with the development of the final search strategies.

This scoping review forms part of an exploratory sequential mixed method study being undertaken by NF as part of a doctor of philosophy (nursing and midwifery) at Curtin University, Western Australia. She is supervised by the other review authors (ZB, JW, KC).

Author contributions

NF: Conceptualization, design and writing of drafts, development of search strategy, editing/writing of final manuscript.

JW, ZB, KC: Conceptualization; supervision of NF; editing and appraisal of drafts; review, editing, and approval of final manuscript.

Funding

NF is a PhD candidate supported by a Western Australian Future Health Research and Innovation Fund, Clinician Research Training Scholarship, Curtin University and North Metropolitan Health Service. The funders had no involvement in the design, conduct, or reporting of this research.

Declarations

Three of the review authors hold current registration as an RN, and all are midwives with expertise in a variety of research methodologies and a wide range of clinical environments, including the care of women and families during pregnancy and pregnancy loss.

Appendix I: Search strategy

CINAHL Ultimate (EBSCOhost)

Search conducted: October 9, 2023

Search #	Search words and phrases	Results retrieved
1	TX midwi* OR TX (nurs* N2 (registered or clinical or specialist or consultant or practitioner)) OR TX Health N2 professional	836,900
2	SU role* or scope or task* or practice* or skill* or knowledge or responsib* or work or attitude* or experience* or perspective* or perception* or support	1,0192,863
3	TX ((under or less of before) N3 (20 week* or twenty week)) OR SU (Pregnan N3 (early or bleeding or viability or loss or uncertain or location or complication* or assessment)) OR SU (miscarr* or ectopic or hyperemesis) OR SU first trimester bleeding OR SU (abortion N2 (threatened or spontaneous))	47,104
4	TX australia* OR canberra OR “new south wales” OR sydney OR victoria OR melbourne OR queensland OR brisbane OR adelaide OR tasmania OR hobart OR perth OR darwin OR “northern territory”	722,708
5	S1 and S2 and S3 and S4 Publication Date: 2005-2023; English Language; Geographic Subset: Australia & New Zealand	96

Search #	Search words and phrases (word variations have been searched)	Results retrieved
1	(midwi* or nurs* or ‘health professional):ti,ab,kw	60,700
2	(role* or scope or job or task* or skill* or knowledge or responsib* or work or attitude* or experience* or perspective* or perception):ti,ab,kw	418,567
3	((under or less or before) NEAR/3 (20 week* or twenty week)):ti,ab,kw OR (Pregnan NEAR/4 (early or bleeding or viability or loss or uncertain or location or complication* or assessment)):ti,ab,kw OR (miscarr* or ectopic or hyperemesis);ti,ab,kw OR (abortion NEAR/2 spontaneous or threatened)):ti,ab,kw	45,777
4	(australia* or canberra or “new south wales” or sydney or victoria or melbourne or queensland or brisbane or adelaide or tasmania or hobart or perth or darwin or “northern territory”):ti,ab,kw	24,805
5	1 and 2 and 3 and 4	94

Search #	Search words and phrases	Results retrieved
1	(midwi* or nurs*).mp. [mp=text, heading word, subject area node word, title]	5540
2	(health adj2 professional).mp.[mp=text, heading word, subject area node word, title]	275
3	1 or 2	5566
4	Role/ or scope of practice/ or job description/	4
5	(role* or scope or task* or practice* or skill* or knowledge or responsib* or work or attitude* or experience* or perspective* or perception* or support).mp.[mp=text, heading word, subject area node word, title]	5843
6	4 or 5	5843
7	first trimester/ or 1st trimester/ or second trimester/ or 2nd trimester/ or pregnancy complications/ or abortion, spontaneous/ or abortion, missed/ or abortion, threatened/ or hyperemesis gravidarum/ or exp pregnancy, ectopic/	1
8	((under or less or before) adj3 (20 week* or twenty week*)).mp.[mp=text, heading word, subject area node word, title]	6
9	(Pregnan* adj4 (early or bleeding or viability or loss or uncertain or location or complication* or assessment)).mp.[mp=text, heading word, subject area node word, title]	107
10	First trimester bleeding.mp.	1
11	(miscarr* or ectopic or hyperemesis).mp.[mp=text, heading word, subject area node word, title]	59
12	7 or 8 or 9 or 10 or 11	139
13	(australia* or canberra or “new south wales” or sydney or victoria or melbourne or queensland or brisbane or adelaide or tasmania or hobart or perth or darwin or “northern territory”).mp.[mp=text, heading word, subject area node word, title]	1135
14	3 and 6 and 12 and 13	48
15	limit 14 to (english language and yr=“2005 -Current”)	48

Search #	Search words and phrases	Results retrieved
1	(midwi* or nurs*).mp. [mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms, population supplementary concept word, anatomy supplementary concept word]	835,629
2	(health adj2 professional).mp. [mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms, population supplementary concept word, anatomy supplementary concept word]	17,348
3	1 or 2	849,479
4	Role/ or scope of practice/ or job description/	27,028
5	(role* or scope or task* or practice* or skill* or knowledge or responsib* or work or attitude* or experience* or perspective* or perception* or support).mp. [mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms, population supplementary concept word, anatomy supplementary concept word]	16,436,352
6	4 or 5	16,439,867
7	first trimester/ or 1st trimester/ or second trimester/ or 2nd trimester/ or pregnancy complications/ or abortion, spontaneous/ or abortion, missed/ or abortion, threatened/ or hyperemesis gravidarum/ or exp pregnancy, ectopic/	160,008
8	((under or less or before) adj3 (20 week* or twenty week*)).mp. [mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms, population supplementary concept word, anatomy supplementary concept word]	1130
9	(Pregnan* adj4 (early or bleeding or viability or loss or uncertain or location or complication* or assessment)).mp. [mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms, population supplementary concept word, anatomy supplementary concept word]	227,467
10	First trimester bleeding.mp.	128
11	(miscarr* or ectopic or hyperemesis).mp. [mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms, population supplementary concept word, anatomy supplementary concept word]	111,126
12	7 or 8 or 9 or 10 or 11	361,580
13	(australia* or canberra or “new south wales” or sydney or victoria or melbourne or queensland or brisbane or adelaide or tasmania or hobart or perth or darwin or “northern territory”).mp. [mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms, population supplementary concept word, anatomy supplementary concept word]	257,434
14	3 and 6 and 12 and 13	275
15	limit 14 to (english language and yr=“2005 -Current”)	230

Search #	Search words and phrases	Results retrieved
1	(midwi* or nurs*).mp. [mp=text, heading word, subject area node word, title]	54,677
2	(health adj2 professional).mp.[mp=text, heading word, subject area node word, title]	870
3	1 or 2	55,211
4	Role/ or scope of practice/ or job description/	0
5	(role* or scope or task* or practice* or skill* or knowledge or responsib* or work or attitude* or experience* or perspective* or perception* or support).mp.[mp=text, heading word, subject area node word, title]	133,246
6	4 or 5	133,246
7	first trimester/ or 1st trimester/ or second trimester/ or 2nd trimester/ or pregnancy complications/ or abortion, spontaneous/ or abortion, missed/ or abortion, threatened/ or hyperemesis gravidarum/or exp pregnancy, ectopic/	0
8	((under or less or before) adj3 (20 week* or twenty week*)).mp.[mp=text, heading word, subject area node word, title]	390
9	(Pregnan* adj4 (early or bleeding or viability or loss or uncertain or location or complication* or assessment)).mp.[mp=text, heading word, subject area node word, title]	22,615
10	First trimester bleeding.mp.	61
11	(miscarr* or ectopic or hyperemesis).mp.[mp=text, heading word, subject area node word, title]	6885
12	7 or 8 or 9 or 10 or 11	27,217
13	(australia* or canberra or “new south wales” or sydney or victoria or melbourne or queensland or brisbane or adelaide or tasmania or hobart or perth or darwin or “northern territory”).mp.[mp=text, heading word, subject area node word, title]	9642
14	3 and 6 and 12 and 13	81
15	limit 14 to (english language and yr=“2005 -Current”)	57

Search #	Search words and phrases	Results retrieved
1	(midwi) OR (nurs) OR (health NEAR/2 professional))	6,077,986
2	(role* OR scope OR task* OR practice* OR skill* OR knowledge OR responsib* OR work OR attitude* OR experience* OR perspective* OR perception* OR support)	99,218,585
3	(under OR less OR before) NEAR/3 (“20 week“ OR “twenty week“)) OR (Pregnan* NEAR/3 (early OR bleeding OR pain OR viability OR loss OR uncertain OR location OR complication* OR assessment)) (miscarr* OR ectopic OR hyperemesis) OR (first trimester bleeding) OR (Abortion NEAR/2 (threatened OR spontaneous OR missed))	621,934
4	(Australia* OR Queensland OR “New South Wales” OR Victoria OR Tasmania OR “Northern Territory” OR Brisbane OR Sydney OR Melbourne OR Hobart OR Adelaide OR Perth OR Canberra OR Darwin)	24,839,686
5	S1 and S2 and S3 and S4 and 2005-2023 and English language	1345
6	S1 and S2 and S3 and S4 and 2005-2023 and English language and Australia	107

Search #	Search words and phrases	Results retrieved
1	Midwi* or nurs* W/2 (registered or clinical or practitioner or specialist or consultant) Or Health W/2 professional	12,226
2	role* or scope or task* or practice* or skill* or knowledge or responsib* or work or attitude* or experience* or perspective* or perception* or support	26,578,249
3	(Under or before or less) W/2 “20 week” OR (Under or before or less) W/2 “twenty week” OR Pregnan* W/4 (early or bleeding or pain or viability or uncertain or location or complication* or assessment or loss) OR miscarr* or ectopic or hyperemesis OR “First trimester bleeding” OR Abortion W/2 (spontaneous or threatened or missed)	26,550
4	S1 and S2 and S3 and 2005 – 2023; Englis; Australia only; Subject area limits (Medicine; Nursing; Psychology; Social sciences; Health professions; Multidisciplinary)	406

Search #	Search words and phrases	Results retrieved
1	midwi* (Topic) or Nurs* NEAR/2 (registered or clinical or practitioner or consultant or specialist) (Topic) or Health NEAR/2 professional (Topic)	181,408
2	TS=(role* or scope or task* or practice* or skill* or knowledge or responsib* or work or attitude* or experience* or perspective* or perception* or support)	19,716,543
3	((((TS=(under NEAR/3 20 week* or less NEAR/3 20 week* or under NEAR/3 twenty week* or less NEAR/3 twenty week* or before NEAR/2 20week* or before NEAR/2 twenty week)) OR TS=(pregnan NEAR/3 (early or bleeding or pain or loss or viability or uncertain or location or complication* or assessment))) OR TS=(first trimester bleeding)) OR TS=(Miscarri* or ectopic or hyperemesis)) OR TS=(Abortion NEAR/2 (spontaneous or threatened))	179,978
4	ALL=(australia* OR canberra OR “new south wales” OR sydney OR victoria OR melbourne OR queensland OR brisbane OR adelaide OR tasmania OR hobart OR perth OR darwin OR “northern territory”)	3,121,237
5	S1 and S2 and S3 and S4 and 2005-2023	186

Author, year	Claringbold et al.,³⁵ 2021
Methodology and methods	Qualitative study Initial audit of basic structure and fundamental function of services Field notes Semi-structured interviews Qualitative description Qualitative content analysis
Phenomena of interest	Provision of psychosocial support to women who experience early pregnancy problems in Australian EPAS
Setting/context	13 EPAS in 3 states in Australia
Sample characteristics	29 “key informants” (health care professionals caring for women in EPAS) Nurse and/or midwife (n=6) Clinic manager/coordinators (n=9) probably midwives or nurses too (overall, 15 of the participants were probably nurses and/or midwives) 9 doctors, 2 pastoral care, 1 counselor, 1 psychologist, and 1 sonographer
Results	5 themes from the data: i) *#Structural elements** of EPAS that may affect women’s distress (location, separate quiet room, staffing, available patient literature/handouts varied) #Most run by a nurse/midwife with resident or registrar—but nurses/midwives seem to have fairly limited roles despite their potential to best provide care ii) #+Emotional care: listening, empathizing, acknowledging, reassuring, guilt mitigation (often restricted in terms of time and experience) iii) #Referral for additional support* (eg, social work, psychologists): initiated only in certain circumstances as determined by staff iv) *#Follow-up (nurse phone calls, GP): not routine, mainly in the context of checking in on physical well-being (expectant or medical management) GPs identified as best placed to provide follow-up care (assumed woman would access if needed) v) Staff training:** little specific early pregnancy loss/psychosocial
Discussion/implications for practice/recommendations/key points	Need for Australian-specific guidelines on EPAS, including recommendations for psychosocial support (benchmarking for emerging services) *#+**Likely EPAS would benefit from midwifery-led care Implications for GPs in terms of capacity to provide/be responsible for more consistent psychosocial follow-up

Authors, year	Claringbold,⁶⁴ 2019 (See also Claringbold et al.,³⁵ 2021)
Methodology and methods	Master of philosophy thesis Mixed methods approach: audit, field notes, and semi-structured interviews Qualitative content analysis Qualitative description
Phenomena of interest	The provision of psychosocial support (ie, the provision of psychological and social resources) in EPAS in Australia
Setting/context	31 key “clinical” or “support” informants previously or currently involved in EPAS (nurses and/or midwives made up around half of the participants)
Sample characteristics	13 EPAS and 2 miscarriage support organizations in Australia
Results	3 categories around psychosocial support: currently provided; considered ideal by participants; barriers to changing Variation in structure and function of EPAS services (staff, physical location, availability of ultrasound) *#+Importance of emotional support (acknowledgment and validation, guilt mitigation, individualized care) Referrals for ongoing psychosocial care rarely reported: role of GP Barriers to providing psychosocial care included time and resources (focus therefore on physical care*) #Most EPAS run by nursing or midwifery staff with junior doctors
Discussion/implications for practice/recommendations/key points	*#+Provision of information, explaining what’s happening, counseling, talking, listening/physical presence, allowing time, memory-making and options for remains #Acknowledgment* of loss and validation of feelings, guilt mitigation #Use of language* that mirrors the woman’s *#Refer to bereavement midwives if over 14 weeks (multidisciplinary** team) #Nurses and midwives in this study appeared to have limited roles #+Increasing the role of nurses and midwives mentioned often: improve efficiency, continuity and emotional support, phone follow-up “the follow up doesn’t have to be a clinical doctor could just be a midwife, nurse.”^(p.61) #+Midwives: more time, counseling, follow-up, focus on emotional* side, organize appointments and follow-up

Authors, year	Crilly et al.,⁶⁸ 2012
Methodology and methods	Qualitative study Semi-structured interviews Content analysis (inclusion in a priori categories of “*#+nursing structure” and “#EPAC nurse role”)
Phenomena of interest	Structures and processes in an Australian ED #*nurse-led EPAC model
Setting/context	Mixed adult and pediatric public hospital with ED seeing approximately 66,000 people per year
Sample characteristics	11 key stakeholders (6 HCPs and 5 women) in delivery and receipt of EPAC care
Results	STRUCTURES (nursing): *#+Clinical nurse consultant with advanced ED skills “Because not all ED nurses are midwives”^(p.72) #+EPAC nurse education workbook #+ED triage nurse: Assess, commence treatment, refer to EPAC. EPAC nurse/clinical nurse consultant: Assess and manage, communication, liaison and referral pathways, review and follow-up, education of staff and women, provide continuity of care PROCESSES (nursing roles): #+Independent: Take history, assess* problem, implement investigations and management, discuss options, signs and symptoms *#+Medical care related: Review referrals, provide and coordinate individualized care, refer women to medical staff, provide telephone advice, education (of women and staff), and emotional support. #+Interdependent: Service development and expansion, care coordination* and case management, counseling
Discussion/implications for practice/recommendations/key point s	#Expansion of service and improvements to physical environment #EPAC nurse “advanced practice role”* (potential for this to be as a nurse practitioner) including: *#Assessment, advanced management and planning, referral*, ability to understand issues of early pregnancy and recognize when a woman was suitable for their scope of practice #Understanding of emergency clinical and service delivery to determine potential hospital admission suitability #+Ability to communicate a woman’s history and management plan *#+Performing/interpreting ultrasounds, vaginal examinations, speculum examinations, initiate Anti-D administration**

Author, year	Wendt et al.,⁷⁴ 2014
Setting/context	An EPAS with EPAP (used by ED staff out of EPAS hours) Regional ED in Queensland, Australia *#+Nurse practitioner-led with medical collaboration**
Participant characteristics	Hemodynamically stable women <20 weeks’ gestation who presented to the ED with complications of early pregnancy over 1 calendar year (n=584) Emergency Department Information System ICD diagnosis codes relating to miscarriage/threatened miscarriage or ectopic pregnancy
Groups	Jan–June PRE-implementation of EPAS/EPAP: n=268 (ED clinicians: NP and MO) July–Dec POST-implementation of EPAS/EPAP: n=316 (ED clinicians: NP [ED or EPAS] and MO [using EPAP])
Outcomes measured	Demographic: age ED characteristics: reason for presentation, triage category, shift of presentation Primary outcomes: Time to see a clinician (NP, MO) Obstetrics and gynecology referral/consult ED LOS Admission Unplanned representations
Results	No significant difference in age or ED characteristics Median gestation of women presenting was 8 weeks No difference in *#+recording of observations in both groups (75%) but increased #+documentation of pain scale* score (13% to 36%, P <0.001) Shorter wait times to see a clinician overall in POST group (P=0.03) Statistically significant increased rates of #ordering QBHCG and pelvic US investigations* LOS times PRE and POST groups: not a statistically significant difference POST group: higher number of representations (likely reflective of decreased admission rates)
Discussion/implications for practice	*#+Improvement in “nursing duties” possible: observations at triage only 75%, pain score documentation still low and these things assist in deciding on need for more emergent care or appropriateness of EPAS referral #+Use of specifically assigned and selected ED nurses (and ‘midwifery trained nurses’) when NP not on duty #+Adjustment of this model to one that is led by “a dedicated NP, advance practice nurse or midwife with multidisciplinary input as required may be worthwhile for further improvements in outcomes”^(p.e53) EPAP: 24/7 operational capacity, #+emergency clinical skill set to identify deterioration, access to radiology/pathology, capacity for follow-up*

Authors, year	Edwards et al.,⁶⁹ 2018
Methodology and methods	Qualitative study In-depth semi-structured interviews Use of memos by researcher Grounded theory methodology (use of storyline technique)
Phenomena of interest	The care of women who present to non-metropolitan EDs (regional, rural, and remote) with first trimester bleeding
Setting/context	11 participants from 3 participant groups: Women presenting to non-metro ED with first trimester bleeding (3) Male partners (2) Nursing staff (6 registered nurses)
Sample characteristics	EDs in non-metropolitan Australian locations
Results	“Threads of care” storyline Women consult with partners but clear division at ED where #nurses consulted* with the women and then women with their partners—#nurses did not show empathy* or acknowledge partners—meaningless words Limited privacy when talking to the *#triage nurse who partners described as impersonal (language and responses) #+Triage* nurse: safety of each patient in context of limited human and physical resources (triage nurse may be performing 2 or more roles triage/treat); frustration at the restrictions on their practice (environment and human resources) *#+Skill in applying appropriate triage** category #Nurses felt there was little they could do to help the woman (although they recognized needs* and understood their anxiety) except apologize for the wait to see doctor; triage nurse stating “there was nothing that could be done.”^(p.296) Wanting recognition/inclusion: Feelings of resentment, burden of having to wait (sometimes in pain); felt their condition not worthy of health care *#+Triage nurse did not listen to concerns, understand, or acknowledge the magnitude of what they were experiencing, did not provide pain relief** #Seeking support* and understanding 2 women had miscarriage into toilet: distressing, away from partner, whether to flush toilet; *#+did nurses need to see the baby/what had passed? Being aware of women’s distress made nurses want to provide best care; heightened awareness (Royal North Shore Hospital incident in New South Wales) but limited capacity #+Less senior staff to consult* and less professional development: nurses relied on/related to their own personal experiences and instincts *#+Triage nurses needed the necessary skills and knowledge to know when to contact the GP #+Nurses prepared women for discharge, providing education* and information, follow-up with GP, hospital or referral Partners only addressed by nurses when *#+advising care and support** for woman at home
Discussion/implications for practice/recommendations/key points	Women and partners “hyperaware” of staff attitudes and willingness to provide *#supportive care** #Women wanted support* of nursing staff and men wanted inclusion and acknowledgment #Nurses should address physical* and psychological impact for women and partners *#+Nurses should not make comments that minimize women’s or their partners’ emotions (“meaningless words/phrases”): therapeutic, open, non-judgmental communication Education and take-home information for woman and partner Nurses’ suggestions included importance of creative practice and innovative solutions, adaptations to #+*EPAS models staffed by nurse practitioners, midwives and ED nurses, professional development opportunities

Authors, year	Griffin et al., ⁷⁰ 2021
Methodology and methods	Qualitative descriptive design Semi-structured interviews Thematic analysis
Phenomena of interest	Nurses’ experiences of caring for women during early pregnancy loss
Setting/context	Public tertiary women’s hospital ED and ward in Western Australia
Sample characteristics	25 registered nurses or registered nurse/midwives who provided early pregnancy loss care >20 weeks
Results	Nurses describe individual holistic care including: *#+Assessing physical** needs (eg, pain, bleeding) #+Emotional care* (acknowledgment of the loss, compassion, appreciating the experience, addressing guilt, and involving/caring for the support person, physical touch, showing vulnerability) #*Information provision #*+Individualized contextualized assessment #+Preparing* women to return to everyday life and face the challenges #Maintain or facilitate a safe secure space* for the woman #*Referring care to multidisciplinary team #*Role models and support for colleagues
Discussion/implications for practice/recommendations/key points	*#+Nurses addressed physical needs first, but emphasis of care was on emotional needs #+Nurses in this setting are performing “emotion* work,” gifting their managed emotions to women (which can be affirming and satisfying rather than draining as in emotional labor)

Authors, year	Harvey,¹⁴ 2012
Methodology and methods	Action research methodology (participatory group approach) Critical theory informed data analysis
Phenomena of interest	The triage and management of pregnant women (early pregnancy under 20 weeks, often threatened miscarriage) attending an ED
Setting/context	Focus groups: 15 ED or obstetrics and gynecology doctors, 7 midwives, 16 ED nurses (total 38 participants) Interviews: 6 women who had presented for triage at the ED when pregnant Medical record review audit: cases of 378 presentations
Sample characteristics	Research hospital was a tertiary level referral hospital in a city in regional Queensland, Australia All pregnant women, regardless of gestation, are triaged in ED, but if 20 weeks or over, go directly to the birth suite with a midwife
Results	3 main themes: i) *#Communication: use of language, interdisciplinary** communication #Communication between HCPs and women lacking compassion* through use of dehumanizing language and the paucity of information provided to women ii) *#+Knowledge: inconsistency in triage and management (formulation of strategies to address care) focus on physical over psychological care #+Knowledge and skill levels including nurses in ED made them less confident when triaging* and managing pregnant women (leading to longer wait times, inadequate or incorrect information, scant follow-up care especially psychological support) #Need for deeper appreciation* of the impact of miscarriage on woman and family iii) Health professional–centered care was dominant over woman-centered care *#+ED nurse’s role: observations, triage, assessment and seek advice from a doctor or midwife, #+pain relief, intravenous fluid administration Clinical decisions made around the “20-week rule”: sometimes not what was best for the woman ED environment not appropriate for non-emergent presentations in early pregnancy: EPUs seen as more appropriate #+Physiological care prioritized over psychological** care: women experiencing early pregnancy loss in the ED felt neglected and unimportant
Discussion/implications for practice/recommendations/key points	This report is a PhD thesis Changes implemented include: #Implementation of miscarriage triage* flow charts and pamphlets, education and resources for staff, improvements to physical environment of ED, collaboration between ED/maternity staff Develop heightened awareness of issues women face when presenting to the ED in early pregnancy that directly affected clinicians’ attitudes and behaviors *#Education from midwifery educators to ED nurses on early pregnancy problems Develop increased awareness of staff roles, which directly affected the communication and relationships between multidisciplinary** areas #Use of midwives’ scope of practice* in the EPAS/EPU setting as recommended in the Hughes Walters report Establishment of an EPAS/EPU at this site and *#+**recommend interim midwife be on duty in the ED 8–5 each day until then

Authors, year	Jensen et al.,⁷¹ 2019
Methodology and methods	Qualitative study Interviews: structured (demographics) and semi-structured (topic of interest) Inductive analysis
Phenomena of interest	Views/perspectives and practices of Australian health professionals caring for women experiencing miscarriage
Setting/context	Urban and rural locations of participants public and private practice settings
Sample characteristics	12 health professionals (8 women and 4 men) recently involved in the care of women experiencing miscarriage 3 midwives (all 3 were nurses as well) 8 doctors 1 sonographer
Results	Psychological impact of miscarriage: broad range of responses/levels of distress, little training about providing #+emotional care (focus on the physical), but high level of perceived competence Perception women with certain situations will feel higher levels of distress (eg, in vitro fertilization, recurrent miscarriage) Focus on #guilt mitigation *#Follow-up care: not routinely provided, only 2 participants asked women about emotional state post miscarriage None #referred women* to external miscarriage support organizations Perceived barriers to care: external factors (time, language, availability of resources), personal protection, risk of becoming indifferent to the personal significance of miscarriage (compassion fatigue)
Discussion/implications for practice/recommendations/key points	Discussion: “Practice” and “perception” mismatch suggested (role of health professional providing support, beliefs about how miscarriage impacts women, different understandings on what information is important to impart) Women see recognition of the significance of the loss as the most important element of their care No strong evidence to suggest the degree of psychological distress is correlated with context #Health professionals focusing on the statistical frequency of miscarriage (devalues the significance* of loss); prefer more information about the etiology of their loss and expected symptoms and reassurance that grief is normal *#Post miscarriage support is important, focus on emotional well-being** “it is imperative that future research aims to better understand the views and practices of emergency department professionals caring for women experiencing miscarriage”^(p.512)

Authors, year	Stratton and Lloyd,⁷⁶ 2008
Phenomena of interest Objectives	Psychosocial and medical support services at or following miscarriage To identify any evidence-based guidelines that described or evaluated hospital-based medical and psychosocial services following a miscarriage To inform a research-practice initiative
Outcomes and contexts included in the review	Outcomes: Miscarriage as a loss Women’s experiences of health professionals Service recommendations Screening for abnormal grief and subsequent pregnancy support Context: Acute care services Follow-up services
Search details	Inclusion of “articles based on the full range of evaluation strategies from feedback to randomised controlled trials”^(p.6) Ovid database Group of search terms suggested (no example search strategy attached) Literature from 1985; current for the publication (2008) Review of bibliographies of included studies until “saturation” reached
Number of studies Participants	29 references cited in the publication, but no specific list of which records were included in the review itself Women experiencing miscarriage under 20 weeks
Appraisal instruments used	No specific tool or review methodology identified
Main results Discussion/Implications for practice	Women’s potential or actual psychological responses to miscarriage ranges; personal meaning of each pregnancy for the woman that informs her responses Male partner important Potential for greater anxiety in subsequent pregnancy Risk factors for increased psychosocial morbidity identified *#+”The qualities that characterize midwifery care, including providing complete information encouraging self-determination and being sensitive to the emotional state are particularly important at the time of loss”^(p.7) but staff may view miscarriage as not as significant** as stillbirth or neonatal loss #Women’s experience of health professionals: loss not important, inadequate information, unsatisfactory explanation, insensitive* comments, lack of regard for emotional needs #Women may find follow-up* appt helpful: must address medical and emotional needs *#+Nurses can “encourage normal grieving by helping discuss miscarriage, ask questions, acknowledge the loss of the baby and associated grief, and talk about cause, blame and guilt” ^(p.9) #+Routine early follow-up* may include a single call from a midwife; women want to an opportunity to discuss emotional and physical experiences; may be an opportunity to assess for psychological morbidity and refer on *#+”A follow-up midwife could assist with health information, assessment and provide referral to medical and/or psychosocial** services as required”^(p.10)

Authors, year	Trostian et al.,⁶⁶ 2022
Phenomena of interest Objectives	Presentations to ED with per vaginum bleeding in early pregnancy Exposure of interest: presentation to the ED Experiences of women and partners, interventions performed Associated patient and health service outcomes
Outcomes and contexts included in the review	Frequency of ED presentation Patient experience and interventions Process Admission rates Cost Representation Discharge pathway Outcome for mother and fetus
Search details	Primary research (all types) English language, 2000 to May 2020 Search terms and variations around “bleeding” “early pregnancy” “patient/woman” “emergency department” Multi-stage search strategy (6 databases) reported in PRISMA diagram
Number of studies Participants	42 included articles (11 Australian) Population: Women with per vaginum bleeding in early pregnancy (<20 weeks)
Appraisal instruments used	Integrative review Adapted quality appraisal tool (Polit & Beck): gauge methodological or theoretical rigor and data relevance, strengths/limitations, classifications of levels of evidence Extracted data compared and grouped, coded by key features to facilitate systematic analysis, identify patterns, establish relationships Development of categories and sub-categories
Main results Discussion/Implications for practice	i) Presentation frequency and characteristics of women: initial presentation (fear for welfare of pregnancy/fetus/self), increased rates of presentation to ED with early pregnancy bleeding (may in part be related to maternal age) ii) Women and their partners experiences in the ED *#+Negative experiences, chaotic ED environment exacerbates anxiety (limited privacy, normalization of environment by health care professionals, partner exclusion), trauma of threatened pregnancy (negative experiences: unacknowledged, dismissed), lack of emotional support, invasive assessments (pain, anxiety, embarrassment, discomfort), inconsistent communication** (about discharge/future plans/direction) leading to isolation and lack of support #Positive experiences: compassion* and empathy, comforting, acknowledgment of distress, EPAS women felt “cared for,” had questioned answered iii) Interventions and treatments Ultrasound (point-of-care access reduced wait time/LOS), *#+speculum/pelvic/vaginal examinations (impact on diagnostic accuracy, management decisions, treatment and discharge pathways), role of health care providers addressed in 6 studies: 2 Australian (Edwards 2018, Crilly 2012) #+emotional support* (and barriers to), lack of clarity around roles, lack of specific *#knowledge and experience: “needs clear, evidence based protocols and procedures that clearly communicate care pathways”^{(p. 6)}, models of care (EPAS in or out of ED), decreased LOS, costs, #+patient-centered comprehensive care from nurses including provision of privacy, education, communication, follow-up, access to ultrasound* for women, less intervention iv) Outcomes Maternal and fetal (pregnancy viability, miscarriage/fetal loss rates), LOS: women perceived care need as urgent, but often long waits, increased LOS out of hours: “Greater insight into the ED healthcare providers experiences and perspectives when caring for women with bleeding is also needed to identify evidence-practice gaps and to inform strategies for improving safety and quality of care.”^{(p. 6)}

Author, year	Bidner et al.,⁷⁵ 2022
Setting/context	Australian university campus and online 2-day antenatal PoCUS workshops for rural and remote health care professionals Prospective single cohort study Access to antenatal US in rural setting can be limited or non-existent #+Training clinicians in antenatal PoCUS* can assist in the assessment and management of pregnant women in these settings Current training programs with the Australasian Society for Ultrasound in Medicine have barriers for rural and remote clinicians
Participant characteristics	Rural and remote clinicians (n=41) providing antenatal care who had access to US equipment: 16 general practitioners #*+25 midwives/nurses
Groups	3 workshops plus pre-reading Mixed groups of 12–16 participants Theory and practicum elements Face-to-face and online mediums
Outcomes measured	Pre- and post-assessing impact of training on: Knowledge, confidence Translation of PoCUS into clinical practice Post workshops: Evaluation Follow-up surveys 3 and 6 months (assess workshops and changes to clinical practice) 2-day follow-up workshop for 9 trainees (8 were midwives/nurses)
Results	22% improvement in pre and post training knowledge test scores 62% of trainees performing PoCUS that assisted in patient management 74% had increased scanning frequency +93% improved scanning confidence Better if they could use their own equipment (then did onsite training at Alice Springs subsequently)
Discussion/implications for practice	Antenatal PoCUS does not replace formal US imaging by trained sonographers #+Detection of life-threatening complications to enable transfer* #*+Only some of the group, of which most were midwives/nurses (8 out of 9), had a follow-up workshop and assessment face-to-face at 12 months Value of training rural clinicians in their own communities Value of interdisciplinary education and training

Author, year	Trostian et al.,⁶⁷ 2023
Setting/context	Health district in New South Wales, Australia with 5 EDs operating (level 2 to level 6) urban and rural locations Level 6 had weekday EPAS Retrospective data linkage cohort study Extraction of data sets: ED, admitted patient, non-admitted patient, costs, pathology, radiology Identification of presentation trends, characteristics, and outcomes for women with early pregnancy bleeding
Participant characteristics	Females of reproductive age 10 – 50 years Early pregnancy per vaginum bleeding
Groups	Study cohort (women of childbearing age with per vaginum bleeding in early pregnancy in ED) Linked data from across 5 EDs within the health district
Outcomes measured	Participant characteristics Return visits ED care: triage times/categories, staff involved in care Types of investigations ED LOS Referral and departure pathways Costs
Results	#7% of presentations seen by a registered nurse and/or an NP #Women who saw a nurse rather than a doctor had a lower LOS/reduced wait time*
Discussion/implications for practice	#The role of the ED NP is expanding rapidly* including seeing and treating women with early pregnancy complications #Further inquiry into the role of the ED NP in care of women with early pregnancy complications recommended

Author, year	Wattimena et al.,⁶⁵ 2013
Setting/context	Emergency department in a large urban hospital Assignment of early pregnancy CMCs to EDs and impact on LOS *#+CMCs responsible for assessment, treatment, and emotional support** for women with early pregnancy problems Retrospective cohort study
Participant characteristics	All women with confirmed pregnancy presenting to the ED between August 2008 and December 2010: <20 weeks’ gestation First presentation with an early pregnancy problem Subsequent discharge home
Groups	1739 women in sample
Outcomes measured	Dependent variable: ED LOS (from arrival → discharge) Other factors that impact on LOS Independent variables: Arrival day/time, suspected or confirmed ectopic, triage category, involvement of CMC, US, attendance at EPAS after discharge
Results	Outcomes for women: Half the sample of women presented during CMC hours *#+Half given Australasian triage score** of 3 45% had LOS > 4 hours Increased LOS associated with arrival out of hours, higher triage category (1-3) and requiring US #*39% were attended by CMC: lower median LOS (P <0.001) 71% attended EPAS as an outpatient after ED discharge
Discussion/implications for practice	*#+*CMC attendance was the most significant factor reducing LOS #Can offer continuity of care and follow-up in the EPAS clinic

Author, year	Cheney and Pelosi,⁴² 2011 See also Wattimena et al ⁶⁵
Phenomenon of interest	Inclusion of #*CMCs from an early pregnancy assessment service into an ED setting
Setting/context	ED and EPAS of Royal Prince Alfred hospital, Sydney, Australia Collaboration project between EPAS and ED
Participant characteristics	Women <20 weeks’ gestation experiencing pain or vaginal bleeding and/or pregnancy loss Staff providing care to women in the ED
Description of main results	CMC positions created with special funding made available following recommendations of the Hughes Walters report (2007) Health Minister allocated funding in support of #*midwives being part of the team providing acute early pregnancy care in the ED “Remarkably positive effect”^[p.67] on management of women presenting to the ED with pain or bleeding <20 weeks (anecdotal from “patients, nurses, doctors, support staff”^[p.67]) Recommendation to conduct qualitative research on this project

PERMALINK

Midwives’ and registered nurses’ role and scope of practice in acute early pregnancy care services: a scoping review

Nicole Freeman

Jane Warland

Kate Cheney

Zoe Bradfield

Abstract

Objective:

Introduction:

Inclusion criteria:

Methods:

Results:

Conclusions:

Review registration:

Introduction

Review question

Inclusion criteria

Participants

Concept

Context

Types of sources

Methods

Search strategy

Study selection

Data extraction

Data analysis and presentation

Critical appraisal

Results

Source of evidence inclusion

Figure 1.

Characteristics of included sources

Review findings

Population, participants, target audience

Context

Concept

Key findings identified from the data

Figure 2.

Physical care a priority

Leaders in psychosocial support

Individual and service coordination

A central communication point

Discussion

Strengths and limitations

Conclusions

Implications for research

Implications for practice

Acknowledgments

Author contributions

Funding

Declarations

Appendix I: Search strategy

CINAHL Ultimate (EBSCOhost)

Cochrane Library

JBI Evidence-based Practice Database (Ovid)

MEDLINE (Ovid)

MIDIRS (Ovid)

ProQuest Central

Scopus

Web of Science Core Collection

Google and Google Scholar

ProQuest Dissertations and Theses

Appendix II: Sources ineligible following full-text review (n=57)

Reason for exclusion: Ineligible phenomena of interest—not role and scope of practice of midwife and/or RN (n=23)

Reason for exclusion: Ineligible context—not acute or subacute care setting (n=10)

Reason for exclusion: Ineligible condition—not early pregnancy (up to 20 weeks; n = 10)

Reason for exclusion: Ineligible condition—not pregnancy related (n=4)

Reason for exclusion: Ineligible setting—not Australia (n=6)

Reason for exclusion: Duplicate study (n=3)

Reason for exclusion: Review protocol for this scoping review (n=1)

Appendix III: Characteristics of included evidence sources

Qualitative and mixed methods studies (n=9)

Evidence synthesis studies/reviews (n=2)

Cohort studies (n=4)

Case report and conference abstract (n=2)

Text/narrative, clinical update, guideline, or website (n=6)

Footnotes

Contributor Information

References

ACTIONS

PERMALINK

Author, year	Mackle and Brownlie,⁷⁸ 2017
Phenomenon of interest	Woman in early pregnancy with HG displaying signs of mental health compromise
Setting/context	*#+ED NPs often the first point of contact for women with nausea and vomiting of pregnancy/HG in early pregnancy ED case study regarding #+*use of the EPDS by an emergency NP
Participant characteristics	Pregnant woman with HG Potentially ‘deteriorating emotional wellbeing’ ^{(p. e334)}
Description of main results	Severe HG can impact on a woman’s mental health and emotional well-being Undetected or untreated mental health problems in pregnancy can impact postnatal well-being and maternal-infant relationships Recognition by ED nurse (NP) of the capacity to *#+utilize the EPDS in an emergency department setting to #+assess mental health* of a woman in early pregnancy *#+Utilization of the EPDS led to referral for perinatal mental health assessment and support**

Author, year	The Royal Women’s Hospital (The Women’s),⁷⁷ 2020
Type of evidence	Hospital clinical guideline
Population represented	Women who have been diagnosed with a miscarriage All clinical staff caring for women with a diagnosis of miscarriage
Phenomenon of interest	Clinical management of miscarriage up to 13 weeks and 6 days
Setting/context	Large urban women’s hospital in Melbourne, Australia EPAS Use of terminology “miscarriage” (<20 weeks) and early pregnancy (<14 weeks) loss to mean the same thing for this guideline (women 14 weeks and over should be “referred to the obstetric team for assessment.”^(p.1)
Stated allegiance/position	Miscarriage is a distressing experience Emotional support and care is essential
Description of main arguments or information	Clinical presentation and diagnosis, treatment options (expectant/medical/surgical) discussed (whose role this is was not identified in the guideline), management and follow-up requirements *#+EPAS staff (all) responsibilities: #+Provide clinical consultations, assessment, advice, management* plans, treatment, and monitoring *#+“Emotional and psychosocial support for women and partners…important part of the service provided by EPAS nurses”^(p.1) #+EPAS nurse: Emotional care/psychosocial support/counseling Physical assessment* (eg, pain, bleeding, uterine tenderness) Medication miscarriage care map (documentation) Information, “options” discussion Facilitate prescription of and administer Anti-D Surgical admission education and preparation Referrals Follow-up (appointments face-to-face or phone, future pregnancy needs, contraception) Collaboration with medical team regarding any histopathology results

Author, year	Summers,⁷⁹ 2012
Type of evidence	Clinical nursing feature/update
Population represented	Pregnant women >20 weeks with severe NVP and/or HG presenting to an ED
Phenomenon of interest	#*Emergency management of HG for ED nurses/NPs
Setting/context	ED settings providing care for pregnant women under 20 weeks with particular focus on the author’s ED site in Queensland, Australia
Stated allegiance/position	Women with severe NVP or HG will present to ED settings and, as such, *#+emergency nurses (particularly ED NPs) must be familiar with the symptoms, causes, clinical signs, complications, and treatments #+NPs need a sound knowledge* of the condition, and can provide assessment, diagnosis, and treatment *#+ Need to identify those who are unwell enough to require further medical assessment and admission** to hospital
Description of main arguments or information	*#+ Required knowledge for nurses and NPs includes: definition, criteria for a diagnosis of HG (as opposed to NVP), differential diagnoses, etiology, signs and symptoms, complications, treatments #+Psychosocial* factors, diet and lifestyle advice, education of woman and family “Emergency nurses may need to combine treatments to manage patients symptoms successfully”^(p.26) *#+Nurse/NP skills: #+Intravenous rehydration, review of bloods, electrolytes if required, prescription/administration of medications, teach acupressure to wrists, total parenteral nutrition/enteral feeding #+Counseling and psychosocial** support: “by providing care and support, and by encouraging family members to do the same, nurses can relieve the psychological burden of the condition”^(p.28)

Author, year	Webster-Bain,⁸³ 2011
Type of evidence	Clinical update: report of project from an Australian ED
Population represented	Pregnant women >20 weeks who present to ED with symptoms of threatened or inevitable miscarriage NP in Australia
Phenomenon of interest	Implementation of NP model in ED specifically for early pregnancy presentations related to vaginal bleeding/possible miscarriage
Setting/context	Sunshine Hospital ED Melbourne, Australia Women in early pregnancy often triaged as less urgent (category 4), subject to long wait times and fragmented care
Stated allegiance/position	12-month funding received for 1 adult NP demonstration project Project focus was care of women <20 weeks in ED with symptoms of threatened miscarriage Author asserts women presenting with similar symptoms from 20 weeks are assessed and managed by midwives in maternity wards
Description of main arguments or information	Clinical explanation of miscarriage (stats, presentation, causes, types) *#+Recommends ED nursing staff closely observe women with heavy bleeding, insert intravenous access, organize for medical or NP assessment (speculum, uterotonics, arrange for dilation and curettage) #+Increasing the NP role and scope of practice: Medical history* and examination, pelvic ultrasound (location, viability), interpretation pathology and imaging results, organize diagnostic and prescribing of Anti-D, liaise with medical staff, assess need for admission, referrals, facilitate discharge Emotional support: counsels families, educates staff provides information, acknowledgment, future pregnancy #*NP project successful: ↑patient satisfaction, ↓waiting and treatment times, economically viable, now a permanent part of hospital ED

Author, year	Wisbey,⁸² 2023
Type of evidence	News article in online GP journal
Population represented	Women less than 20 weeks pregnant with symptoms of early pregnancy loss (bleeding and/or pain), NVP, urinary or bowel concerns Women with urgent gynecological concerns including post-op concerns and contraceptive device issues GPs providing care and advising treatment for women described in above pregnant/gynae population
Phenomenon of interest	Impact on/recommendations from GPs regarding this virtual assessment service
Setting/context	Tertiary women’s hospital in Adelaide, Australia #Virtual (midwifery) assessment service* for women of South Australia Open every day 8am to 4pm GP practices
Stated allegiance/position	GPs supportive but have some concerns: Will GPs receive communication/update that a woman has been to the service and what was done? “Kept in the loop”: educational opportunity for the GP too Will GPs de-skill in this area of practice that used to be the domain of the GP (a specialist themselves in generalist medicine) if conditions are diverted to “specialist” services? GPs broad scope of practice sets them apart in the health care workforce Political views reported from current health minister
Description of main arguments or information	Urgent assessment with midwife via video link #+Women can then speak with midwife* and then an obstetrics and gynecology doctor, if required, through the video link service Year-long pilot is underway after successful trial Feedback from women regarding service and that she did not have to organize childcare to go into the hospital Pregnancy loss a deeply personal experience and not having to attend ED assists with this for women “Harnessing technology to provide compassionate, patient focused care”^{(para 24)}

Author, year	Women’s and Children’s Hospital Adelaide,⁸¹ 2023
Type of evidence	Consumer website
Population represented	Women less than 20 weeks pregnant with symptoms of early pregnancy loss (bleeding and/or pain), NVP, urinary or bowel concerns Women with urgent gynecological concerns including post-op concerns and contraceptive device issues
Phenomenon of interest	Virtual women’s assessment service #*Led by midwives
Setting/context	Tertiary women’s hospital in Adelaide, Australia #Virtual (midwifery) assessment service* for women of South Australia Open every day 8am to 4pm
Stated allegiance/position	#+Still works on a triage system #If midwife feels condition warrants further attention woman will be referred on* (examples given including pathology, GP, hospital) #*+Attending midwives have “special interest” in early pregnancy and gynecological care
Description of main arguments or information	Women access care from home or community #+ ‘Highly experienced’ midwives available to assess and refer* via telehealth portal Improves access for women with barriers such as where they live #+Wide range of reproductive health concerns addressed by midwives (not nurses) +Can provide sick certificates

Author, year	Wright,⁸⁰ 2021
Type of evidence	Opinion piece/narrative
Population represented	Women in early pregnancy and/or those who experience miscarriage
Phenomenon of interest	The “12-week rule” (not telling anyone about pregnancy in the first 12 weeks)
Setting/context	Published in a medical journal in Australia Reflections on an earlier article by a doctor describing her personal journey of miscarriage
Stated allegiance/position	The “silence” of hiding news of pregnancy and then of subsequent miscarriage exacerbates the silent culture around miscarriage This can affect the woman’s capacity to recover emotionally from the experience
Description of main arguments or information	Health professionals should encourage women to share their news of being pregnant early and be open about things that can go wrong ED environment may not be ideal for women experiencing miscarriage Potential for significant psychological morbidity for some women particularly if emotional needs are not acknowledged and met *#+Bereavement midwife: nurse…. important not to minimize** the loss, “be in that space, sit with someone who’s just so sad about their loss”^(para.22)