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CHAPTER 1

MATERNITY AND WOMEN'S HEALTH CARE TODAY

  • Copyright © 2019 by Elsevier, Inc. All rights reserved.

HISTORICAL PERSPECTIVES ON CHILDBEARING

  • Introduction to Childbearing History

    • “Granny” midwives played a central role in childbirth before modern medicine.

    • Emergence of medical management shaped childbirth practices.

    • Significant discoveries influenced maternal and infant care practices.

    • Women held a critical role in childbirth processes.

    • Hospital births became a standard practice, indicating a shift from home births.

    • Technological advances significantly improved maternity care.

    • Consumer demands have become pivotal in shaping maternity care practices.

    • Government involvement and federal funding have addressed childbirth practices and healthcare distribution.

    • Noted issues regarding the inequitable distribution of healthcare across different demographics.

CONTINUATION OF HISTORICAL PERSPECTIVES ON CHILDBEARING

  • Impact of Consumer Demands

    • Consumer involvement heightened interest in new childbirth methods.

    • Emphasized benefits of extended parental contact with newborns post-birth.

CONTINUATION OF HISTORICAL PERSPECTIVES ON CHILDBEARING

  • Family-Centered Maternity Care

    • Recognizes the physical and psychosocial needs of families during childbirth.

    • Aims to foster the family unit throughout the childbirth experience.

    • Key Principles of Family-Centered Care:

    • Childbirth is typically viewed as a normal, healthy event.

    • Acknowledges that childbirth impacts the entire family unit.

    • Importance of family involvement in making decisions about care.

    • Recognition of various forms of family and support systems.

CHOICES IN CHILDBIRTH: HEALTH CARE PROVIDER

  • Types of Health Care Providers

    • Certified Nurse-Midwife (CNM):

      • Provides care for women at low risk for complications and refers to physician when needed.

    • Nurse Practitioner (NP):

      • Offers prenatal and newborn care but does not perform deliveries.

    • Physician:

      • Potential for couples to explore multiple providers to determine the best fit for their needs.

CHOICES IN CHILDBIRTH: BIRTH SETTING

  • Variety of Birth Settings

    • Traditional hospital settings:

      • Labor, Delivery, Recovery rooms (LDRs) and Labor, Delivery, Recovery, Postpartum rooms (LDRPs).

    • Birth centers, which can be freestanding facilities.

    • Home births as a modality of childbirth.

    • Insurance coverage may restrict choice in providers and settings.

CHOICES IN CHILDBEARING: SUPPORT AND EDUCATION

  • Support Systems

    • Support Person may include:

      • Father of the baby, relative, friend, doula (trained labor support), siblings.

      • Discussion of the controversial nature of children's presence during childbirth.

    • Education:

    • Recognizes the critical importance of perinatal education for parents.

CURRENT TRENDS IN PERINATAL AND WOMEN'S HEALTH CARE

  • Healthy People 2020 Goals

    • Aim to attain high quality, long lives free from preventable disease.

    • Objectives include achieving health equity and eliminating disparities.

    • Focus on creating supportive social and physical environments promoting health for all demographics.

    • Advancing quality of life, ensuring healthy development and promoting healthy habits throughout all life stages.

CONTINUATION OF CURRENT TRENDS IN PERINATAL AND WOMEN'S HEALTH CARE

  • Safety and Quality Initiatives

    • The Joint Commission's Perinatal Core Measures emphasize certain quality objectives:

    • Decreasing the rate of elective deliveries.

    • Reducing cesarean birth rates.

    • Increasing antenatal steroid administration in preterm labor cases.

    • Reducing the incidence of newborn septicemia or bacteremia.

    • Promoting exclusive breastfeeding practices.

CONTINUATION OF CURRENT TRENDS IN PERINATAL AND WOMEN'S HEALTH CARE

  • Interprofessional Collaboration

    • Emphasis on collaboration and education among different health professionals for improved maternal health.

    • Recognizing the role of agencies like AWHONN in developing quality measures for perinatal and women's health nursing.

CONTINUATION OF CURRENT TRENDS IN PERINATAL AND WOMEN'S HEALTH CARE

  • Cost Containment Factors

    • Overview of how cost containment affects maternity care deliveries.

    • Implications on length of hospital stays and complications post-discharge.

    • Legislative mandates impacting teaching time and nursing education.

CONTINUATION OF CURRENT TRENDS IN PERINATAL AND WOMEN'S HEALTH CARE

  • Community-Based Nursing

    • Importance of understanding diverse communities in maternal health nursing.

    • Collaboration within multidisciplinary teams to coordinate comprehensive care.

    • Various forms of perinatal home care, including antepartum and postpartum/natal care for high-risk neonates.

CONTINUATION OF CURRENT TRENDS IN PERINATAL AND WOMEN'S HEALTH CARE

  • Technological Advances

    • Denotes the significant role of technology in modern healthcare:

    • Telemedicine applications, utilization of Electronic Medical Records (EMR), and the rise of complementary and alternative medicine approaches.

    • Considerations for safety and consistency with holistic nursing care practices.

    • Challenges noted include nursing shortages and the impact of retiring baby boomers on staffing levels.

STATISTICS ON MATERNAL, INFANT, AND WOMEN'S HEALTH

  • Maternal and Infant Mortality

    • Discussion of pregnancy-related maternal mortality and notable disparities present in health outcomes.

    • Assessment of infant mortality rates and causes associated with it, such as congenital malformations, premature birth, and pregnancy complications.

    • Reference to Healthy People 2020 objectives related to infant mortality.

CONTINUATION OF STATISTICS ON MATERNAL, INFANT, AND WOMEN'S HEALTH

  • Adolescent Pregnancy Statistics

    • Observation of declining teen birthrates yet highlighting the higher rate of teen pregnancy in the U.S. compared to other industrialized nations.

    • Underlying issues concerning women's health include rising concerns about cardiovascular disease and obesity rates.

STANDARDS OF PRACTICE

  • Overview of standards pertaining to perinatal and women's health nursing including:

    • Agency standards: Established criteria for care.

    • Organizational standards: Guidelines followed by healthcare institutions.

    • Legal standards: Established laws governing nursing practices and patient care.

CHANGING ROLE OF NURSES

  • Nurses are now functioning across varied, specialized areas in the healthcare field:

    • Taking on primary responsibility for independent functions; teaching and counseling patients.

CONTINUATION OF CHANGING ROLE OF NURSES

  • Therapeutic Communication

    • Importance of developing interpersonal skills in nursing practice.

    • Focus on effective teaching methods and critical thinking skills necessary for optimal patient care.

CONTINUATION OF CHANGING ROLE OF NURSES

  • Techniques of Therapeutic Communication

    • Communication in nursing is purposeful, goal-directed and focused.

    • Key techniques include:

    • Clarifying: Ensuring understanding of messages.

    • Reflecting: Echoing what the patient expresses to show understanding.

    • Maintaining Silence: Allowing time for thoughts without interrupting.

    • Questioning: Effectively gathering information.

    • Directing: Steering conversation when necessary.

    • Being Aware of Communication Blocks: Recognizing and overcoming barriers in communication.

CONTINUATION OF CHANGING ROLE OF NURSES

  • Teaching and Learning Principles

    • Emphasis on several principles such as:

    • Readiness of learners.

    • Importance of active participation.

    • Value of repetition in learning.

    • significance of positive feedback to encourage learning.

    • Role modeling as an influential teaching method.

    • Resolving conflict and frustration to enhance the learning experience.

    • Progressing from simple concepts to complex ideas.

    • Utilizing a variety of teaching methods and presenting content in small segments for better retention.

CONTINUATION OF CHANGING ROLE OF NURSES

  • Factors Influencing Learning

    • Noted factors that influence learning include:

    • Developmental level of the individuals.

    • Language proficiency of the learner.

    • Cultural background and its effects on learning.

    • Previous experiences impacting present learning.

    • Physical environment conducive to learning.

    • Organization and skill of the instructor impacting effectiveness.

OTHER NURSING ROLES

  • Expounding on the diverse roles of nurses includes:

    • Collaborator: Works with various health care team members to coordinate comprehensive care for women and infants.

    • Researcher: Engages with evidence-based practice, ensuring nursing care is based on research findings for better patient outcomes.

    • Advocate: Acts in the best interest of patients, giving voice to those who may be unable to advocate for themselves.

    • Manager: Oversees healthcare delivery and ensures quality standards are met within practices.

ADVANCED PREPARATION FOR MATERNAL-NEWBORN AND WOMEN'S HEALTH NURSES

  • Certified Nurse-Midwives (CNMs):

    • Registered nurses who have followed specialized training and clinical experience during pregnancy and childbirth.

    • Services offered include counseling and support for childbearing families alongside annual well-woman exams.

    • Adoption of a noninterventionist and supportive approach to childbirth practices.

CONTINUATION OF ADVANCED PREPARATION FOR MATERNAL-NEWBORN AND WOMEN'S HEALTH NURSES

  • Nurse Practitioners:

    • Registered Nurses with advanced education and specialization.

    • Women’s Health Nurse Practitioners (WHNPs): Provide ongoing reproductive and gynecologic care spanning from adolescence onwards.

    • Family Nurse Practitioners (FNPs): Deliver holistic preventive care to families of various ages.

    • Neonatal Nurse Practitioners (NNPs): Focuses on the care of high-risk newborns, particularly in neonatal intensive care environments.

    • Pediatric Nurse Practitioners (PNPs): Ensure health maintenance for infants and children, acting when medical intervention isn't necessary.

CONTINUATION OF ADVANCED PREPARATION FOR MATERNAL-NEWBORN AND WOMEN'S HEALTH NURSES

  • Clinical Nurse Specialists (CNS):

    • Registered nurses who have completed advanced education (master's or doctoral).

    • Focused on caring for women with complex health issues related to childbirth, without taking on primary care responsibilities.

    • Core competencies include:

    • Direct care consultation.

    • Systems leadership roles.

    • Collaborating with multidisciplinary teams.

    • Coaching newer nurses.

    • Engaging in research activities.

    • Ethical decision-making.

NURSING RESEARCH

  • Importance placed on demonstrating improved patient outcomes through evidence-based practices that are also cost-effective.

  • Nurses are encouraged to both generate and utilize research effectively.

  • Highlighting organizations like the National Institute of Nursing Research (NINR) and the National Institutes of Health (NIH) as pivotal in supporting nursing research efforts.

EVIDENCE-BASED PRACTICE (EBP)

  • Definition: EBP is described as a problem-solving approach to care intended to enhance the quality of care and achieve the best patient outcomes.

  • Involvement of various initiatives from organizations such as AWHONN, the Agency for Healthcare Research and Quality (AHRQ), and the Institute of Medicine (IOM) to enhance practice guidelines.

  • Reference to the Cochrane Collaboration for evidence generation and systematic reviews.

CRITICAL THINKING

  • Definition: Critical thinking is essential for effective clinical judgment in nursing.

  • Steps involved in critical thinking include:

    • ABCDEs: A systematic approach to prioritization in patient care.

    • Recognizing assumptions: Understanding personal biases and beliefs influencing care decisions.

    • Examining biases: Identifying potential biases that could affect clinical outcomes.

    • Recognizing the need for closure: Understanding when to draw conclusions based on assessment data.

    • Skilled data management: Properly evaluating and interpreting patient data.

    • Acknowledging emotional and environmental factors that may affect patient care.

APPLICATION OF THE NURSING PROCESS: MATERNAL-NEWBORN AND WOMEN'S HEALTH NURSING

  • Assessment

    • Types of assessments: Screening assessments and focused assessments aimed at identifying patient problems.

    • Process involves recognizing nursing diagnoses.

  • Planning

    • Involves setting priorities and establishing clear goals and expected outcomes for patient care.

CONTINUATION OF APPLICATION OF THE NURSING PROCESS: MATERNAL-NEWBORN AND WOMEN'S HEALTH NURSING

  • Planning (continued)

    • Development of appropriate interventions:

    • Interventions for actual nursing diagnoses.

    • Preventive interventions addressing potential risks.

    • Wellness interventions supporting patient health.

    • Implementation: Execution of nursing interventions as per the plan.

    • Evaluation: Assessment of the effectiveness of individualized nursing care plans, relating the nursing process back to critical thinking for improved outcomes.

CHAPTER 1
MATERNITY AND WOMEN'S HEALTH CARE TODAY

  • Copyright 2019 by Elsevier, Inc. All rights reserved.

HISTORICAL PERSPECTIVES ON CHILDBEARING

  • Evolution of Midwifery and Medical Management

    • “Granny” Midwives: Historically, these were women in the community who provided care based on experience rather than formal education. They were the primary providers until the early 20^{th} century, particularly in rural and underserved areas.

    • The Shift to Medical Management: In the early 1900s, childbirth moved from the home to the hospital. This led to increased use of anesthesia (e.g., “twilight sleep”) and obstetric interventions like forceps.

    • Technological and Scientific Milestones:

      • Discovery of germ theory by Louis Pasteur and the importance of handwashing by Ignaz Semmelweis significantly reduced puerperal fever (childbed fever).

      • Development of antibiotics (penicillin) and blood transfusion techniques addressed the leading causes of maternal death: infection and hemorrhage.

    • Hospitalization Trends: By 1960, 99\% of births in the United States occurred in hospitals. While safety improved for high-risk cases, the environment often became impersonal and highly regulated.

  • Impact of Consumer Demands

    • In the 1950s and 1960s, parents began questioning the rigid hospital protocols that separated mothers from infants and excluded fathers from the birth process.

    • Natural Childbirth Movement: Influenced by Grantley Dick-Read and Fernand Lamaze, parents sought methods to manage pain without heavy sedation, leading to the establishment of prepared childbirth classes.

    • Parent-Infant Bonding: Research by Klaus and Kennell emphasized the “critical period” immediately after birth for skin-to-skin contact to foster attachment.

  • Family-Centered Maternity Care

    • This model shifts the focus from the provider to the family unit, recognizing that birth is a significant life event rather than just a medical procedure.

    • Core Principles:

      1. Normalcy of Childbirth: Childbirth is viewed as a healthy physiologic process for most women.

      2. Family Integrity: The family is defined by the mother and includes anyone she identifies as supportive (e.g., partner, grandparents).

      3. Empowerment: Providing the family with enough information and support to make informed decisions about their care.

CHOICES IN CHILDBIRTH: HEALTH CARE PROVIDER

  • Primary Care Providers

    • Certified Nurse-Midwife (CNM):

      • Highly trained RNs with graduate degrees (MSN or DNP) and certification from the American Midwifery Certification Board.

      • Focus on holistic, non-interventionist care for low-risk pregnancies.

      • They have hospital privileges to deliver babies and can prescribe medications in all 50 states.

    • Nurse Practitioner (NP):

      • Includes Women's Health Nurse Practitioners (WHNPs) and Family Nurse Practitioners (FNPs).

      • Primarily provide prenatal, postpartum, and gynecological care in outpatient settings; they generally do not attend hospital deliveries.

    • Obstetricians and Specialists:

      • Obstetricians: Physicians specialized in pregnancy and birth, capable of performing surgeries (C-sections) and managing complications.

      • Perinatologists (Maternal-Fetal Medicine Specialists): Physicians who manage the most high-risk pregnancies.

CHOICES IN CHILDBIRTH: BIRTH SETTING

  • Hospital Settings

    • LDR (Labor, Delivery, Recovery): The most common setting where the woman stays in one room for the three stages of birth but is moved to a postpartum room after 1 to 2 hours.

    • LDRP (Labor, Delivery, Recovery, Postpartum): A “single-room maternity care” concept where the mother and baby stay in the same room from admission until discharge.

  • Birth Centers

    • Freestanding facilities designed for low-risk women who want a home-like environment with less intervention but with professional staff (usually CNMs).

    • Require a transfer plan to a hospital if complications arise.

  • Home Births

    • Provides the highest level of control and intimacy. While controversial among some medical organizations, it is seen as a safe option for healthy, low-risk women when attended by a qualified provider.

CURRENT TRENDS IN PERINATAL AND WOMEN'S HEALTH CARE

  • Healthy People 2020/2030 Objectives

    • Targets include reducing the maternal mortality rate to 11.4 per 100,000 live births and reducing the infant mortality rate to 6.0 per 1,000 live births.

    • Increasing the proportion of infants who are breastfed exclusively through 6 months.

  • Safety and Quality Initiatives: Perinatal Core Measures

    • Focus areas to improve outcomes:

      • PC-01: Reducing elective deliveries prior to 39 weeks gestation to prevent neonatal respiratory issues.

      • PC-02: Reducing the rate of Cesarean births among “nulliparous, term, singleton, vertex” (NTSV) women.

      • PC-05: Increasing exclusive breast milk feeding before hospital discharge.

  • Cost Containment

    • Managed care has led to “short-stay” maternity care, where mothers may be discharged within 24 to 48 hours. This increases the need for comprehensive discharge teaching and home health follow-ups.

STATISTICS ON MATERNAL AND INFANT HEALTH

  • Maternal Mortality

    • The U.S. has seen an unexpected rise in maternal mortality compared to other developed nations.

    • Significant racial disparities exist: Black women are approximately 3 to 4 times more likely to die from pregnancy-related causes than White women.

  • Infant Mortality

    • Defined as death within the first year of life.

    • Leading Causes: Congenital malformations, Low Birth Weight (LBW) / Preterm birth, and Sudden Infant Death Syndrome (SIDS).

  • Adolescent Pregnancy

    • Although rates have declined significantly, the U.S. still has higher rates than most Western European countries. Teen mothers are at higher risk for low weight gain, preterm labor, and PIH (Pregnancy-Induced Hypertension).

NURSING ROLES AND ADVANCED PRACTICE

  • Therapeutic Communication Techniques

    • Clarifying: “So, you are saying the pain is sharper when you move?”

    • Reflecting: “You seem concerned about how your toddler will react to the new baby.”

    • Communication Blocks: Avoiding false reassurance (e.g., “Don't worry, everything will be fine”) or giving unsolicited advice.

  • Advancement in Nursing

    • Clinical Nurse Specialist (CNS): Focuses on improving patient outcomes through staff education and policy changes for complex cases like high-risk antepartum patients.

    • Evidence-Based Practice (EBP): Integrating the best research evidence with clinical expertise and patient values. For example, using delayed cord clamping based on recent evidence of improved neonatal iron stores.

THE NURSING PROCESS IN MATERNITY

  • Assessment: Includes the head-to-toe assessment plus specific obstetric checks (fundal height, Fetal Heart Tones [FHT], and presence of edema).

  • Planning: Setting measurable, time-limited goals (e.g., "Patient will demonstrate three breastfeeding positions by the end of the shift").

  • Implementation: Performing interventions like administering Rhogam to an Rh-negative mother.

  • Evaluation: Determining if outcomes were met. If a mother cannot demonstrate breastfeeding properly, the plan must be revised.