Professional Documents
Culture Documents
Contemporary
Maternity Nursing
C h a p t e r
1
SHANNON E. PERRY
LEARNING OBJECTIVES
Describe the scope of maternity nursing. Examine social concerns in maternity nursing.
Evaluate contemporary issues and trends in Explain quality management and standards of
maternity nursing. practice in the delivery of nursing care.
Describe sociopolitical issues affecting the Debate ethical issues in perinatal nursing.
care of women and infants. Examine the Healthy People 2010 goals related
Compare selected biostatistical data among to maternal and infant care.
races and countries.
ELECTRONIC RESOURCES
Additional information related to the content in Chapter 1 can be found on
the companion website at or on the interactive companion CD
http://evolve.elsevier.com/Lowdermilk/Maternity/ NCLEX Review Questions
NCLEX Review Questions
WebLinks
1
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CONTEMPORARY ISSUES
BOX 1-1 AND TRENDS
The Vision for Women and Their Health
Structure of Health Care Delivery
The International Confederation of Midwives envisions a The changing health care delivery system offers opportuni-
world where ties for nurses to alter nursing practice and improve the way
Women are respected and treated as persons in their care is delivered through managed care, integrated delivery
own right in all societies.
systems (IDSs), and redefined roles. Nurses have been crit-
Women stand as equal partners with men in the world
order. ically important in developing strategies to improve the well-
Women are recognized as crucial to the health of any being of women and their infants and have led the efforts
nation. to implement clinical practice guidelines and to practice us-
Women and their families are part of a health care sys- ing an evidence-based approach. Through professional as-
tem with high-quality care and easy access when sociations, nurses can have a voice in setting standards and
needed. in influencing health policy by actively participating in the
Women have the right to choose from among safe op-
education of the public and of state and federal legislators.
tions for care throughout their lives, including high-
quality, state-of-the-art care from competent providers Changes in the health care market are influencing the way
who truly care about the woman and her health. health care providers can care for their patients. Health spend-
Women are educated and empowered to delight in a ing varies considerably among nations (Table 1-1). In the
strong sense of self, to trust their bodies, to plan United States during 2001 health spending accounted for
their pregnancies, and to make wise choices in their 13.9% of the gross domestic product (GDP); in Canada 9.7%
health care. of the GDP was spent on health care (Reinhardt, Hussey, &
Women experience a reasonable standard of living, in-
Anderson, 2004). A national nursing shortage exists, and
cluding a clean and safe environment, healthy food,
and a reasonable place to live. nurses are working longer hours. The longer hours jeopardize
Women need have no fear for their lives or the lives of patient safety (Rogers, Hwang, Scott, Aiken, & Dinges, 2004).
their babies when they are pregnant. A minimum nurse-patient ratio has been legislated.
Women believe that birth is normal and prefer to avoid The role of the nurse is evolving from primary caregiver
unnecessary intervention. to the leader of an interdisciplinary care team. Documen-
tation of patient outcomes has become essential (see later dis-
From The International Confederation of Midwives: Internet document avail-
able at www.internationalmidwives.org/vision.htm (accessed June 15,
cussion). Advanced practice roles will increase as nurses as-
2002). sume more responsibility for patient care.
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BOX 1-2
Historic Milestones in the Care of Mothers and Infants
TABLE 1-1
Integrative Health Care
International Comparison of Percentage of Integrative health care encompasses complementary and
Gross Domestic Product Spent on Health alternative therapies in combination with conventional
Care in 2001
Western modalities of treatment. Many popular alternative
COUNTRY PERCENTAGE healing modalities offer human-centered care based on
philosophies that recognize the value of the patients in-
United States 13.9
Switzerland 11.1
put and honor the individuals beliefs, values, and desires
Germany 10.7 (Fig. 1-1). The focus of these modalities is on the whole per-
Canada 9.7 son, not just on a disease complex (Box 1-3). Patients of-
France 9.5 ten find that alternative modalities are more consistent with
Australia 9.2 their own belief systems and also allow for more patient au-
New Zealand 8.1 tonomy in health care decisions. Complementary and al-
Japan 8.0
ternative therapies are identified throughout the text with
United Kingdom 7.6
an icon .
Source: Reinhardt, U., Hussey, P., & Anderson, G. (2004). U.S. Health
Increasing numbers of U.S. adults are seeking alternative
care spending in an international context. Health Affairs, 23(3), 10-25. and complementary health care, which exceeds visits paid
001-020_CH01_Lowdermilk.qxd 9/29/05 1:18 PM Page 4
Childbirth Practices
Prenatal care may promote better pregnancy outcomes by
providing early risk assessment and promoting healthy be-
haviors such as improved nutrition and smoking cessation.
In 2003 84.1% of all women received care in the first
trimester and 3.5% had late or no prenatal care. There is dis-
parity in use of prenatal care in the first trimester by race and
ethnicity: non-Hispanic whites (89%), non-Hispanic blacks
(76%), and Hispanic (77.4%) (Martin, Kochanek, Strobino,
Guyer, & MacDorman, 2005).
Women can choose physicians or nurse-midwives as pri-
mary care providers. In 2002, physicians attended 91% and
nurse-midwives attended 8% of all births (Martin et al.,
Fig. 1-1 Nurse and patient during guided imagery session.
2003). Hospital births accounted for 99% of births. Of the
(Courtesy Nurses Certificate Program in Interactive Imagery,
Foster City, CA.) out-of-hospital births, 65% were in the home, 27% in free-
standing birth centers, and 2% in clinics or doctors offices
(Martin et al., 2003). Cesarean births increased to 27.6% of
to U.S. primary care physicians. Use of complementary and live births in the United States in 2003, the highest rate ever
alternative therapies is increasing rapidly in Canada (Verhoef in the United States, whereas the rate of vaginal births af-
& Findlay, 2003). Approximately 40% of the general popu- ter cesarean (VBACs) declined to 10.6% (Martin et al.,
lation uses complementary and alternative therapies (Barrett, 2005). Women who choose nurse-midwives as their primary
2003), and most of these users do not tell their physicians. providers actively participate in childbirth decisions and re-
Annual expenditures related to alternative therapies are es- ceive fewer interventions such as epidural analgesia for la-
timated at $27 billion, over half of which consists of out-of- bor (Jackson et al., 2003) (Table 1-2).
pocket expenses not covered by medical insurance (Eisenberg Changes are occurring in the conduct of the second stage
et al., 1998). Throughout the world the use of traditional of labor (from 10 cm dilation to birth of the baby); positions
medicine presents unique challenges in terms of policy, ef- are varied, with more emphasis on upright posture. The ar-
ficacy, accessibility, and utilization (World Health Organi- bitrary limit of 2 hours for the second stage is less rigid, as
zation, 2002). delayed pushing (waiting until the forces of labor propel the
In 1992 the National Institutes of Health (NIH) devel- fetus down in the birth canal instead of encouraging push-
oped the Office of Alternative Medicine (OAM). Mandated ing as soon as the cervix is 10 cm dilated) is instituted. De-
by Congress, the OAM was designed to support research and layed pushing conserves the energy of the mother, results in
evaluation of various alternative and complementary fewer instrumental deliveries, and is less costly. The rates of
modalities and to provide information to health care con- episiotomy are declining, resulting in fewer severe perineal
sumers about such modalities. In 1998 Congress instituted lacerations. Midwives perform fewer episiotomies than do
the National Center for Complementary and Alternative physicians.
Medicine (NCCAM), which incorporates the work of the The method of analgesia varies, depending on the con-
OAM in its mission and function. dition and choice of the mother and the preferences of the
providers. Mothers typically are awake and aware during la-
bor and birth. Contrasting philosophies exist regarding anal-
BOX 1-3 gesia during labor. Some women prefer to experience the sen-
Five Types or Classifications of sations of birth with little or no analgesia; others opt for
Complementary or Alternative Therapies
TABLE 1-2
Alternative medical systems (e.g., homeopathic and
naturopathic medicine; traditional Chinese medicine) Percent of Women Undergoing Various
Mind-body interventions (e.g., patient support groups, Obstetric Procedures
cognitive-behavioral therapy; meditation, prayer, art, PROCEDURE PERCENT
music, dance)
Biologically based therapies (e.g., herbs, foods, Electronic fetal monitoring 85.2
vitamins) Ultrasound 68.0
Manipulative and body-based methods (e.g., chiro- Induction of labor 20.6
practic or osteopathic manipulation, massage) Stimulation of labor 17.3
Energy therapies (e.g., qi gong, reiki, therapeutic touch, Tocolysis 2.1
use of electromagnetic fields) Amniocentesis 2.0
Source: Hawks, J., & Moyad, M. (2003). CAM: Definition and classification Data from Martin, J., et al. (2003). Births: Final data for 2002. National Vi-
overview. Urology Nursing, 23(3), 221-223. tal Statistics Reports, 52(10), 1-114.
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Views of Women
Women must be viewed holistically and in the context in
which they live. Their physical, mental, and social factors
must be considered because these interdependent compo-
nents influence health and illness. Even the language health
care professionals use to describe women and their problems
needs to be examined (Freda, 1995). For example, practi-
tioners describe women who have an incompetent cervix,
who fail to progress, or who have an arrest of labor. They
may describe a fetus as having intrauterine growth retar-
Fig. 1-2 Father cutting cord of his newborn daughter. dation. They also allow women a trial of labor. Freda
(Courtesy Tricia Olson, North Ogden, UT.) suggests that practitioners use phrases such as women who
001-020_CH01_Lowdermilk.qxd 9/29/05 1:18 PM Page 6
have recurrent premature dilation of the cervix or fetuses weapons. Approximately 8% of pregnant women are bat-
whose intrauterine growth has been restricted. There is a tered. Violence is associated with complications of pregnancy
movement to refer to spontaneous pregnancy loss as a mis- such as bleeding, miscarriage, and preterm labor and birth.
carriage instead of the more politically charged abortion,
especially when talking to patients (Freda, 1999). HIV and AIDS in Pregnancy
and the Newborn
Breastfeeding in the Workplace Cases of perinatally acquired human immunodeficiency virus
Women are a significant proportion of the workforce. Com- (HIV) infection and AIDS peaked in 1992; since then the rate
panies are recognizing that it is good business to retain good of AIDS among infants has continued to decline. Treatment
employees and are making provisions for women returning with zidovudine of mothers who tested positive for HIV be-
to work after childbirth. Lactation rooms that provide space fore giving birth has resulted in a dramatic decrease in the
and privacy for pumping are available at many work sites and number of infants infected with the virus; highly active an-
on college campuses (Fig. 1-4). In some instances, breast- tiretroviral therapy (HAART) and elective cesarean birth
feeding women bring their babies to work. Since 1999, by reduce the rate of mother-to-child transmission of HIV
law, women may breastfeed in federal buildings and on fed- (European Collaborative Study, 2005). Universal HIV test-
eral property. Some states have enacted legislation to ensure ing and access to quality prenatal care will contribute to re-
that mothers can breastfeed their babies in public places. ducing the transmission of HIV and prolonging survival. For
These efforts may help mothers breastfeed longer and meet women in labor who have had no prenatal care, rapid HIV
the recommendation of the American Academy of Pediatrics testing is available (European Collaborative Study, 2005).
that breastfeeding continue for at least 1 year.
International Concerns
Family Leave Female genital mutilation, infibulation, and circumcision are terms
The Family and Medical Leave Act of 1993 provides for up used to describe procedures in which part or all of the female
to 12 weeks of unpaid leave to eligible employees for birth, external genitalia are removed for cultural reasons (Ahmed
adoption, or foster placement; for care of a child, spouse, or & Abushama, 2005; Momoh, 2004). Worldwide, many
parent who is seriously ill; or for the employees own illness. women undergo such procedures. With the growing num-
This is of great benefit to women because they are usually ber of immigrants from African and other countries in which
the primary caretakers of family members. female genital mutilation is practiced, nurses will increasingly
encounter women who have undergone the procedure. Eth-
Violence ical dilemmas arise when the woman requests that after birth
Violence is a major factor affecting pregnant women. This the perineum be repaired as it was after infibulation and the
includes battering (which may increase during pregnancy), health care provider believes that such repair is unethical.
rape or other sexual assaults, and attacks with various The International Council of Nurses and other health pro-
fessionals have spoken out against the procedures as harm-
ful to womens health.
annual maternal mortality rate (number of maternal deaths Institute of Nursing Research has included the goal of re-
per 100,000 live births) was 8.9 (Kochanek, Murphy, ducing disparities in its strategic plan and supports research
Anderson, & Scott, 2004). The United States is tied for sev- for that purpose. The nation must make a concerted effort
enteenth among developed countries. Reduction of mater- to eliminate health disparities.
nal mortality rates is a key goal of the Millennium Devel-
opment Goals (2004). Health Literacy
There are significant racial differences in the rates: Almost half of all American adults have difficulty in un-
African-American women have a maternal mortality rate four derstanding and using health information (Nielsen-
times higher than that of Caucasian women. The maternal Bohlman, Panzer, & Kindig, 2004). Health literacy is the
mortality rate was 30 per 100,000 for African-American degree to which individuals have the capacity to obtain,
women, in contrast with 8.1 per 100,000 for Caucasian process, and understand basic health information and ser-
women (Chang et al., 2003). The predominant causes of vices needed to make appropriate health decisions
these deaths are embolism, hemorrhage, gestational hyper- (Ratzan & Parker, 2000). Literacy encompasses a set of skills
tension, and infection (Chang et al., 2003). The Healthy People including reading, writing, mathematics, and speech and
2010 goal of 3.3 maternal deaths per 100,000 poses a sig- speech comprehension. Health literacy involves a spectrum
nificant challenge. To achieve this goal, early diagnosis and of abilities, ranging from reading an appointment slip to in-
appropriate intervention must occur. Worldwide strategies terpreting medication instructions. These skills must be as-
to reduce maternal mortality rates include improving access sessed routinely to recognize a problem and accommodate
to skilled attendants at birth, providing postabortion care, patients with limited literacy skills. An excellent resource is
improving family planning services, and providing adoles- Teaching Patients with Low Literacy Skills (2nd ed.) (Doak,
cents with better reproductive health services (Millennium Doak, & Root, 1996).
Development Goals, 2004). Individuals and groups for whom English is a second lan-
guage often lack the skills necessary to seek medical care and
Involving Consumers and function adequately in the health care setting. Lack of English
Promoting Self-Care fluency is a barrier, and communication difficulties continue
Self-care is appealing to both patients and the health care sys- to affect access to care, particularly in such areas as making
tem because of its potential to reduce health care costs. Ma- appointments, applying for services, and obtaining trans-
ternity care is especially suited to self-care because child- portation. As a result of the increasingly multicultural
bearing is essentially health focused, women are usually well
when they enter the system, and visits to health care pro-
viders can present the opportunity for health and illness in-
terventions. Measures to improve health and reduce risks as- Critical Thinking Exercise
sociated with poor pregnancy outcomes and illness can be
Health Literacy
addressed. Topics such as nutrition education, stress man-
agement, smoking cessation, alcohol and drug treatment, im- Yu Mei speaks English as her second language; she
speaks Cantonese at home. She has been diagnosed with
provement of social supports, and parenting education are
a urinary tract infection. While giving Yu Mei instructions
appropriate for such encounters. about perineal hygiene and medication administration,
the nurse notes that Yu Mei listens intently to her in-
Efforts to Reduce Health structions, nods affirmatively, and looks at the patient in-
Disparities formation handout.
Significant disparities in morbidity and mortality rates are 1 EvidenceIs there sufficient evidence to draw con-
experienced by African-Americans, Native Americans, His- clusions about Yu Meis comprehension of the oral and
written instructions?
panics, Alaska Natives, and Asian and Pacific Islanders.
2 AssumptionsWhat assumptions can be made about
Shorter life expectancy, higher infant and maternal mortal- patient understanding of the information and in-
ity rates, more birth defects, and more sexually transmitted structions?
infections are found among these groups. The cause-specific a. Mode of patient education
mortality ratio was three to four times higher for black b. Reading and comprehension
women when compared with white women for each cause c. Processing of information
of death (Chang et al., 2003). The disparities are thought to d. Nonverbal language
e. Clarity and use of words
result from a complex interaction among biologic factors,
f. Use of interpreters
environment, and health behaviors. Disparities in education 3 What implications and priorities for nursing care can
and income are associated with differences in occurrence of be drawn at this time?
morbidity and mortality. NIH has a commitment to im- 4 Does the evidence objectively support your conclusion?
prove the health of minorities and provides funding for 5 Are there alternative perspectives to your conclusion?
research and training of minority researchers. The National
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U.S. population, there is a more urgent need to address Increase in High Risk
health literacy as a component of culturally and linguistically Pregnancies
competent care. Health care providers contribute to health The number of high risk pregnancies has increased, which
literacy by using simple common words, avoiding jargon, means that a greater number of women are at risk for poor
and assessing whether the patient is understanding the dis- pregnancy outcomes. Escalating drug use (ranging from 11%
cussion. Speaking slowly and clearly and focusing on what to 27% of pregnant women, depending on geographic lo-
is important will increase understanding (Roberts, 2004). cation) has contributed to higher incidences of prematurity,
LBW, congenital defects, learning disabilities, and withdrawal
High-Technology Care symptoms in infants. Alcohol use in pregnancy has been as-
Advances in scientific knowledge and the large number of sociated with miscarriages, mental retardation, LBW, and fe-
high risk pregnancies have contributed to a health care sys- tal alcohol syndrome.
tem that emphasizes high-technology care. Maternity care The two most frequently reported maternal medical risk
has been extended to preconception counseling, more and factors are hypertension associated with pregnancy and
better scientific techniques to monitor the mother and fe- diabetes. The birthrate of higher-order multiples (triplet,
tus, more definitive tests for hypoxia and acidosis, and quadruplet, and greater) rose 2% from 2000 to 2001
neonatal intensive care units. Point-of-care testing is avail- (Martin et al., 2005). Multiple births now account for 3.2%
able. Personal data assistants are used to enhance compre- of all births (Martin et al., 2005). The cesarean birthrate in-
hensive care (Lewis & Sommers, 2003); the electronic med- creased to 27.6% of all births in 2003, with primary ce-
ical record is being used. Virtually all women are monitored sareans rising to 19.1% and VBACs dropping to 10.6%
electronically during labor despite the lack of evidence of ef- (Martin et al., 2005). This cesarean rate is significantly
ficacy of such monitoring. higher than the Healthy People 2010 goal of 15%. Births of
Telemedicine is an umbrella term for the use of com- babies born vaginally assisted with forceps or with vacuum
munication technologies and electronic information to pro- extraction decreased to 5.9% (Arias, MacDorman, Strobino,
vide or support health care when the participants are sepa- & Guyer, 2003).
rated by distance. Telemedicine permits specialists, including
nurses, to provide health care and consultation when dis- High Cost of Health Care
tance separates them from those needing care. For example, Health care is one of the fastest-growing sectors of the U.S.
Baby CareLink (Gray et al., 2000) is an Internet-based pro- economy. The United States spends proportionately more
gram that incorporates teleconferencing and the World Wide on health care than any of the other 190 countries that make
Web to enhance interactions among health care providers, up the World Health Organization (Reinhardt, Hussey, &
families, and community providers. It includes distance Anderson, 2004). A shift in demographics, an increased em-
learning, virtual home visits, and remote monitoring of the phasis on high-cost technology, and the liability costs of a
infant after discharge. This technology has the potential to litigious society contribute to the high cost of care. Most re-
save billions of dollars annually spent on health care. searchers agree that the cost of caring for the increased num-
Strides are being made in identifying genetic codes, ber of LBW infants in neonatal intensive care units con-
and genetic engineering is taking place. In general, high- tributes significantly to the overall health care costs.
technology care has flourished while health care has been Midwifery care has helped contain some health care
relatively neglected. These technologic advances have also costs. However, not all insurance carriers reimburse nurse
contributed to higher health care costs. Nurses must use practitioners and clinical nurse specialists as direct care pro-
caution and prospective planning and assess the effect of viders. Nor do they reimburse for all services provided by
the emerging technology. nurse-midwives, a situation that continues to be a problem.
Nurses must become involved in the politics of cost con-
Community-Based Care tainment because they, as knowledgeable experts, can pro-
A shift in settings, from acute care institutions to the home, vide solutions to many of the health care problems at a rel-
has been occurring. Even childbearing women at high risk atively low cost.
are cared for in the home. Technology previously available Early postpartum discharge programs also are used to re-
only in the hospital is now found in the home. This has af- duce costs. The American Academy of Pediatrics has pub-
fected the organizational structure of care, the skills required lished minimal criteria for early discharge of a newborn
to provide such care, and the cost to consumers. (American Academy of Pediatrics Committee on Fetus and
Home health care also has a community focus. Nurses are Newborn, 2004) (see Box 16-2.)
involved in caring for women and infants in homeless shel-
ters, in caring for adolescents in school-based clinics, and in Limited Access to Care
promoting health at community sites, churches, and shop- Barriers to access must be removed so pregnancy outcomes
ping malls. Nursing education curricula are increasingly com- can be improved. The most significant barrier to access is the
munity based. inability to pay. Lack of transportation and dependent child
001-020_CH01_Lowdermilk.qxd 9/29/05 1:18 PM Page 10
care are other barriers. In addition to a lack of insurance and to patient care became evident. Nurses from the University
high costs, a lack of providers for low-income women exists. of Iowa developed a comprehensive standardized language
Many physicians either refuse to take Medicaid patients or that describes interventions that are performed by general-
take only a few such patients. This presents a serious prob- ist or specialist nurses. This language is included in the
lem because a significant proportion of births are to moth- Nursing Interventions Classification (NIC) (Dochterman &
ers who receive Medicaid. Bulachek, 2004). Interventions commonly used by maternal-
child nurses include those in Box 1-6.
TRENDS IN NURSING PRACTICE
Evidence-Based Practice
The increasing complexity of care for maternity and Evidence-based practiceproviding care based on evidence
womens health patients has contributed to specialization gained through research and clinical trialsis being in-
of nurses working with these patients. This specialized creasingly emphasized. Although not all practice can be ev-
knowledge is gained through experience, advanced degrees, idence based, practitioners must use the best available in-
and certification programs. Nurses in advanced practice formation on which to base their interventions. The
(e.g., nurse practitioners and nurse-midwives) may provide Association of Womens Health, Obstetric and Neonatal
primary care throughout a womans life, including during Nurses (AWHONN) Standards and Guidelines for Professional
the pregnancy cycle. In some settings, the clinical nurse spe- Nursing Practice in the Care of Women and Newborns (1998) and
cialist and nurse practitioner roles are blended, and nurses the Standards for Professional Perinatal Nursing Practice and
deliver high-quality, comprehensive, and cost-effective care Certification in Canada (2002) include an evidence-based ap-
in a variety of settings. Lactation consultants provide ser- proach to practice. Discussion of nursing care and evidence-
vices in the postpartum unit or on an outpatient basis, in- based nursing boxes throughout this text provide examples
cluding home visits. of evidence-based practice in perinatal nursing.
AWHONN has conducted six research-based practice
Nursing Interventions projects (Box 1-7). These projects were conducted in several
Classification states, and staff nurses were involved in their implementa-
When the National Institute of Medicine proposed that all tion and in data collection. The AWHONN practice guide-
patient records be computerized by the year 2000, a need for lines incorporate evidence-based practices for second-stage
a common language to describe the contributions of nurses labor management, continence for women, breastfeeding
BOX 1-6
Childbearing Care Interventions
From Dochterman, J., & Bulachek, G. (2004). Nursing interventions classification (NIC) (4th ed.). St. Louis: Mosby.
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BOX 1-8
Association of Womens Health, Obstetric and Neonatal Nurses Research Priorities for
Womens and Neonatal Health
STRATEGIES TO PROMOTE HEALTHY BEHAVIORS Reducing genetically determined risk through appropri-
IN WOMEN ACROSS THE LIFESPAN ate screening
Prevention of unintended pregnancy
Cardiovascular health, including smoking cessation MODELS OF NURSING CARE DELIVERY
Weight management and nutrition Strategies to increase diversity of the nursing workforce
Menstrual and menopausal adjustment and symptom Effect of workforce diversity on patient outcomes
management Comparative studies of quality, patient outcomes, and
Cancer screening and risk reduction cost across the following:
Chronic illness self-care (e.g., diabetes) Providers (physicians, nurses, advanced practice
Social risks (poverty, addiction, sexual risks, violence) nurses)
Promotion of womens mental health and stress man- Delivery settings (medical centers, birth centers, pri-
agement mary care, home care)
Practice decisions and decision making (levels and
REDUCING HEALTH DISPARITIES types of clinical decision making and interventions)
Delivering culturally competent care Staff development and support models
Enhancing access to and use of health care Models of care delivery in prenatal and antepartum
Reducing disparities in rates of low birth weight care
Improving breastfeeding rates among low-income and
minority women
EVIDENCE-BASED PRACTICE
Early Postnatal Discharge of Healthy Mothers and Babies
Reference: Brown, S. et al. (2002). Early postnatal discharge from hospital for healthy mothers and term infants (Cochrane Review). In The Cochrane Library, Issue 2, 2005. Chichester,
UK: John Wiley & Sons.
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Cochrane Pregnancy and one that incorporates the best resolutions of the problem
Childbirth Database that fit the agencys unique population and mission char-
The Cochrane Pregnancy and Childbirth Database was first acteristics. The agency continually compares its performance
planned in 1976 with a small grant from the World Health against the best in the industry and the best of a specific
Organization to Dr. Iain Chalmers and colleagues at Oxford. function.
In 1993, the Cochrane Collaboration was formed, and the
Oxford Database of Perinatal Trials became known as the Clinical Benchmarking
Cochrane Pregnancy and Childbirth Database. The Cochrane Clinical benchmarking is a process used to compare ones
Collaboration oversees up-to-date, systematic reviews of ran- own performance against the performance of the best in an
domized controlled trials of health care and disseminates area of service. Benchmarking supports and promotes con-
these reviews. The premise of the project is that these types tinual quality improvement and helps the organization re-
of studies provide the most reliable evidence about the effects main competitive in the health care market.
of care. Collaborative benchmarking involves sharing strategies
The evidence from these studies should encourage prac- and outcomes and leads to the development of new best
titioners to implement useful measures and to abandon practices (Clinical Benchmarking, 2005). Areas of practice
those that are useless or harmful. Studies are ranked in six routinely monitored in perinatal nursing include hospital
categories: length of stay, maternal mortality rate, infant mortality rate,
1. Beneficial forms of care cesarean birth rate, epidural rate, and episiotomy rate.
2. Forms of care that are likely to be beneficial
3. Forms of care with a trade-off between beneficial and A Global Perspective
adverse effects Advances in medicine and nursing have resulted in increased
4. Forms of care with unknown effectiveness knowledge and understanding in the care of mothers and in-
5. Forms of care that are unlikely to be beneficial fants and reduced perinatal morbidity and mortality rates.
6. Forms of care that are likely to be ineffective or However, these advances have affected predominantly the
harmful industrialized nations. For example, the majority of the 3.2
Practices that have been reviewed by the Collaboration million children living with HIV or AIDS acquired the in-
are identified with a symbol throughout this text. fection through perinatal transmission and live in sub-
Saharan Africa. This illustrates the inequities that exist be-
Outcomes-Oriented Practice tween industrialized and resource-poor parts of the world
Outcomes of care (that is, the effectiveness of interventions (Cohan, 2003).
and quality of care) are receiving increased emphasis. As the world becomes smaller because of travel and com-
Outcomes-oriented care measures effectiveness of care munication technologies, nurses and other health care pro-
against benchmarks or standards. It is a measure of the value viders are gaining a global perspective and participating in
of nursing using quality indicators and answers the question, activities to improve the health and health care of people
Did the patient benefit or not benefit from the care pro- worldwide (Katz & Hirsch, 2003). Nurses participate in med-
vided? (Moorhead, Johnson, & Maas, 2004). The Outcome ical outreach, providing obstetric, surgical, ophthalmologic,
Assessment Information Set (OASIS) is an example of an orthopedic, or other services; attend international meetings;
outcome system important for nursing. Its use is required conduct research; and provide international consultation. In-
by the Centers for Medicare and Medicaid Services, for- ternational student and faculty exchanges occur (Perry &
merly the Health Care Financing Administration (HCFA), Mander, 2005) (Fig. 1-5). More articles about health and
in all home health organizations that are Medicare ac- health care in various countries are appearing in nursing jour-
credited. The Nursing Outcomes Classification (NOC) is nals. Several schools of nursing in the United States are
an effort to identify outcomes and related measures that can World Health Organization Collaborating Centers.
be used for evaluation of care of individuals, families, and
communities across the care continuum (Moorhead, Millennium Development Goals
Johnson, & Maas, 2004). An example of outcomes classifi- The member states of the United Nations adopted the Mil-
cation is provided in Table 1-3. lennium Declaration in September 2000. The Millennium
Development Goals are a guide to implementing the Mil-
Best Practices as Goal of Care lennium Declaration. The goals are to (1) eradicate extreme
A program or service that has been recognized for excellence poverty and hunger, (2) achieve universal primary education,
is considered to be a best practice. A best practice must pro- (3) promote gender equality and empower women, (4) reduce
vide a better or a new way to achieve goals and be sound child mortality, (5) improve maternal health, (6) combat HIV
from operational, clinical, and financial perspectives. To de- and AIDS, malaria, and other diseases, (7) ensure environ-
termine best practices, information is collected from simi- mental sustainability, and (8) develop a global partnership
lar institutions. Staff members then identify solutions that for development. The target date for achievement of the
have been successful in addressing specific needs and select goals is 2015. The goals help to define a yardstick with which
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TABLE 1-3
Nursing Outcomes Classification
TAXONOMY
Level 1: Domain IVHealth Knowledge and Behavior
Outcomes that describe attitudes, comprehension, and actions with respect to health and illness
Level 2: QHealth Behavior
Outcomes that describe an individuals actions to promote, maintain, or restore health
Level 3: 1607Prenatal Health Behavior
Care Recipient: Data Source:
Scale(s)Never demonstrated to Consistently demonstrated
Definition: Personal actions to promote a healthy pregnancy and a healthy newborn
Outcome Target Rating: Maintain at Increase to
Never Rarely Sometimes Often Consistently
Prenatal Health Behavior demonstrated demonstrated demonstrated demonstrated demonstrated
Overall Rating 1 2 3 4 5
Indicators:
160701 Maintains healthy precon- 1 2 3 4 5 NA
ceptual state
160702 Uses proper body 1 2 3 4 5 NA
mechanics
160703 Keeps appointments for 1 2 3 4 5 NA
prenatal care
160704 Maintains healthy weight 1 2 3 4 5 NA
gain pattern
160705 Receives proper dental care 1 2 3 4 5 NA
160706 Uses seat belt appropriately 1 2 3 4 5 NA
160707 Attends childbirth education 1 2 3 4 5 NA
classes
160709 Participates in regular 1 2 3 4 5 NA
exercise
160710 Maintains adequate nutrient 1 2 3 4 5 NA
intake for pregnancy
160711 Practices safe sex 1 2 3 4 5 NA
160721 Uses medications as 1 2 3 4 5 NA
prescribed
160712 Consults health care profes- 1 2 3 4 5 NA
sional concerning use of
nonprescription drugs
160713 Avoids environmental 1 2 3 4 5 NA
hazards
160714 Avoids exposure to in- 1 2 3 4 5 NA
fectious diseases
160715 Avoids recreational drugs 1 2 3 4 5 NA
160716 Abstains from alcohol 1 2 3 4 5 NA
160717 Abstains from tobacco use 1 2 3 4 5 NA
160718 Avoids teratogenic agents 1 2 3 4 5 NA
160719 Avoids abusive situations 1 2 3 4 5 NA
Outcome Content References: Bell, R., & ONeill, M. (1994). Exercise and pregnancy: A review. Birth, 21(2), 85-95; Crowell, D. (1995). Weight change in the
postpartum period: A review of the literature. Journal of Nurse-Midwifery, 40(5), 418-423; Freda, M. et al. (1993). What pregnant women want to know: A
comparison of client and provider perceptions. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 22(3), 237; Kearney, M. et al. (1995). Salvaging
self: A grounded theory of pregnancy on crack cocaine. Nursing Research, 44(4), 208-213; McFarlane, J. et al. (1996). Abuse during pregnancy: Associations
with maternal health and infant birth weight. Nursing Research, 45(1), 37-42; Olds, S. et al. (1996). Maternal-newborn nursing: A family-centered approach
(5th ed.). Menlo Park, CA: Addison-Wesley; Shapiro, H. (1993). Prenatal education in the work place. AWHONNs Clinical Issues in Perinatal and Womens
Health Nursing 4(1), 113-121; Summers, L. (1993). Preconception care: An opportunity to maximize health in pregnancy. Journal of Nurse-
Midwifery, 38(4), 188-198.
Source: Moorhead, S., Johnson, M., & Maas, M. (2004). Nursing outcomes classification (NOC) (3rd ed.). St Louis: Mosby.
001-020_CH01_Lowdermilk.qxd 9/29/05 1:18 PM Page 15
STANDARDS OF PRACTICE
AND LEGAL ISSUES IN
DELIVERY OF CARE
Nursing standards of practice in perinatal nursing have been
described by several organizations, including the American
Nurses Association (ANA), which publishes standards for
maternal-child health nursing; AWHONN, which publishes
standards of practice and education for perinatal nurses and
womens health (Box 1-9); the American College of Nurse
Midwives (ACNM), which publishes standards of practice
for midwives; and the National Association of Neonatal
Nurses (NANN), which publishes standards of practice for
Fig. 1-5 U.S. nursing students and faculty posing with neonatal nurses. These standards reflect current knowledge,
head nurses in a pediatric hospital in China as part of an in- represent levels of practice agreed on by leaders in the spe-
ternational perspectives in nursing course. (Courtesy Shan- cialty, and can be used for clinical benchmarking.
non Perry, Phoenix, AZ.)
In addition to these more formalized standards, agencies
have their own policy and procedure books that outline stan-
to measure results. With the rich resources of many devel- dards to be followed in that setting. In legal terms, the stan-
oped countries, poorer countries can be provided with ad- dard of care is that level of practice that a reasonably pru-
ditional resources and assistance (Millennium Development dent nurse would provide. In determining legal negligence,
Goals, 2004). the care given is compared with the standard of care. If the
BOX 1-9
Standards of Care for Women and Newborns
Planning Collaboration
Development of a plan of care Involvement of patient, significant others, and other
health care providers in the provision of patient care
Implementation
Performance of interventions for the plan of care Research
Use of research findings in practice
Evaluation
Evaluation of the effectiveness of interventions in relation Resource Utilization
to expected outcomes Consideration of factors related to safety, effectiveness,
and costs in planning and delivering patient care
STANDARDS OF PROFESSIONAL PERFORMANCE
THAT DELINEATE ROLES AND BEHAVIORS FOR Practice Environment
WHICH THE PROFESSIONAL NURSE IS Contribution to the environment of care delivery
ACCOUNTABLE
Quality of Care Accountability
Systemic evaluation of nursing practice Legal and professional responsibility for practice
Performance Appraisal
Self-evaluation in relation to professional practice stan-
dards and other regulations
Source: Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN). (1998). Standards and guidelines for professional nursing practice in
the care of women and newborns (5th ed.). Washington, DC: AWHONN.
001-020_CH01_Lowdermilk.qxd 9/29/05 1:18 PM Page 16
standard was not met and harm resulted, negligence oc- Failure to Rescue
curred. The number of legal suits in the perinatal area has Failure to rescue is used to evaluate the quality and quan-
typically been high. As a consequence, malpractice insurance tity of nursing care by comparing the number of surgical pa-
costs are high for physicians, nurse-midwives, and nurses tients who develop common complications who survive ver-
who work in labor and delivery. sus those who do not (Simpson, 2005). As mothers and
babies are generally healthy, complications leading to death
LEGAL TIP Standard of Care in obstetrics are comparatively rare. Simpson (2005) proposes
When you are uncertain about how to perform a pro- evaluating the perinatal teams ability to decrease risk of ad-
cedure, consult the agency procedure book and follow verse outcomes by measuring processes involved in common
the guidelines printed therein. These guidelines are the complications and emergencies in obstetrics. Key compo-
standard of care for that agency. nents of failure to rescue are (1) careful surveillance and iden-
tification of complications, and (2) acting quickly to initi-
Risk Management ate appropriate interventions and activating a team
Risk management is an evolving process that identifies risks, response. For the perinatal nurse, this involves timely iden-
establishes preventive practices, develops reporting mecha- tification of complications, appropriate interventions, and
nisms, and delineates procedures for managing lawsuits. efforts of the team to minimize patient harm. Maternal com-
Nurses should be familiar with concepts of risk management plications that are appropriate for process measurement are
and their implications for nursing practice. These concepts placental abruption, postpartum hemorrhage, uterine rup-
can be viewed as systems of checks and balances that ensure ture, eclampsia, and amniotic fluid embolism (Simpson,
high-quality patient care from preconception until after 2005). Fetal complications include nonreassuring fetal heart
birth. Effective risk management minimizes the risk of in- rate pattern, prolapsed umbilical cord, shoulder dystocia, and
jury to patients and the number of lawsuits against nurses. uterine hyperstimulation (Simpson, 2005). Perinatal nurses
Each facility or site develops site-specific risk management can use these complications to develop a list of expectations
procedures based on accepted standards and guidelines. The for monitoring, timely identification, interventions, and roles
procedures and guidelines must be reviewed periodically. of team members. The list can be used to evaluate the peri-
To decrease risk of errors in the administration of med- natal teams response.
ications, the Joint Commission on Accreditation of Health-
care Organizations (JCAHO) has developed a list of ab- ETHICAL ISSUES IN
breviations, acronyms, and symbols not to use (Table 1-4). PERINATAL NURSING
In addition, each agency must develop its own list.
Ethical concerns and debates have multiplied with the in-
Sentinel Events creased use of technology and with scientific advances. For
JCAHO describes a sentinel event as an unexpected oc- example, with reproductive technology, pregnancy is now
currence involving death or serious physical or psycholog- possible in women who thought they would never bear
ical injury, or the risk thereof. Serious injury specifically in- children, including some who are menopausal or post-
cludes loss of limb or function. These events are called menopausal. Should scarce resources be devoted to
sentinel because they signal a need for an immediate in- achieving pregnancies in older women? Is giving birth to a
vestigation and response (JCAHO, 2002). child at an older age worth the risks involved? Should older
TABLE 1-4
JCAHO Do Not Use List
ABBREVIATION POTENTIAL PROBLEM PREFERRED TERM
Source: Do not use list required in 2004. LTC Update, Issue 3, 2003.
001-020_CH01_Lowdermilk.qxd 9/29/05 1:18 PM Page 17
parents be encouraged to conceive a baby when they may health care. The clinician can identify problems in the health
not live to see the child reach adulthood? Should a woman and health care of women and infants. Through research,
who is HIV positive have access to assisted reproduction nurses can make a difference for these patients.
services? Should third-party payers assume the costs of re-
productive technology? With induced ovulation and in vitro Ethical Guidelines for
fertilization, multiple pregnancies occur, and multifetal Nursing Research
pregnancy reduction (selectively terminating one or more Nurses must protect the rights of human subjects (that is, pa-
fetuses) may be considered. Innovations such as intrauter- tients) in all of their research. For example, nurses may collect
ine fetal surgery, fetoscopy, therapeutic insemination, ge- data on or care for patients who are participating in clinical
netic engineering, stem cell research, surrogate childbearing, trials. The nurse ensures that the participants are fully informed
surgery for infertility, test tube babies, fetal research, and and aware of their rights as subjects. Research with perinatal
treatment of VLBW babies have resulted in questions about patients may create ethical dilemmas for the nurse. For ex-
informed consent and allocation of resources. The intro- ample, participating in research may cause additional stress to
duction of long-acting contraceptives has created moral a woman concerned about outcomes of genetic testing or one
choices and policy dilemmas for health care providers and who is waiting for an invasive procedure. Obtaining amniotic
legislators; that is, should some women (substance abusers, fluid samples or performing cordocentesis poses risks to the
women with low incomes, or women who are HIV positive) fetus. The nurse may be involved in determining whether
be required to take the contraceptives? With the potential the benefits of research outweigh the risks to the mother and
for great good that can come from fetal tissue transplanta- the fetus. Following the ANA ethical guidelines in the conduct,
tion, what research is ethical? What are the rights of the em- dissemination, and implementation of nursing research helps
bryo? Should cloning of humans be permitted? Discussion nurses ensure that research is conducted ethically.
and debate about these issues will continue for many years.
Nurses and patients, as well as scientists, physicians, attor-
COMMUNITY ACTIVITY
neys, lawmakers, ethicists, and clergy, must be involved in
the discussions. Examine a daily newspaper for 7 days. Identify ar-
ticles reporting topics related to maternity or re-
productive health.
RESEARCH IN How many articles did you identify? What are
PERINATAL NURSING the topics? Are they local or national issues?
Is the reporter a health reporter? A local or na-
Research plays a vital role in the establishment of a mater- tional columnist? Male or female?
nity nursing science. Nurses should promote research fund- What is the slant of the articles? Are the re-
ing and conduct research on maternity and womens health, ports favorable to women and reproductive
health? Does the viewpoint of the articles limit
especially concerning the effectiveness of nursing strategies
reproductive freedom or infringe on womens
for these patients. Research can validate that nursing care rights?
makes a difference. For example, although prenatal care is What conclusions can you draw related to the
clearly associated with healthier infants, no one knows exactly treatment of womens issues and reproductive
which nursing interventions produce this outcome. Many health in your community?
possible areas of research exist in maternity and womens
Key Points
Maternity nursing focuses on women and their in- Evidence-based practice, outcomes orientation,
fants and families during the childbearing cycle. best practices, and clinical benchmarking are em-
phasized in current practice.
Nurses caring for women can play an active role
in shaping health care systems to be responsive Risk management and learning from sentinel
to the needs of contemporary women. events can improve quality of care.
Childbirth practices have changed to become more Healthy People 2010 provides goals for maternal
family focused and to allow alternatives in care. and infant health.
Canada ranks nineteenth and the United States Research plays a vital role in improving the health
ranks twenty-seventh among industrialized na- of women and infants.
tions in infant mortality. Ethical concerns have multiplied with increasing
Integrative medicine combines modern technology use of technology and scientific advances.
with ancient healing practices and encompasses
the whole of body, mind, and spirit.
001-020_CH01_Lowdermilk.qxd 9/29/05 1:18 PM Page 18
Resources
Alternative Health News Online Emerging Infectious Diseases
www.altmedicine.com Centers for Disease Control and Prevention
www.cdc.gov/ncidod/eid/index.htm
Alternative Medicine Foundation
www.amfoundation.org Global Health Council
www.globalhealth.org
Alternative Medicine: Health Care Information Resources
http://hsl.mcmaster.ca/tomflem/altmed.html HerbMed
www.herbmed.org
American College of Nurse Midwives
www.acnm.org Homebirth Information
www.changesurfer.com/Hlth/homebirth.html
American Massage Therapy Association
www.amtamassage.org International Council of Nurses
3, Place jean Marteau
Ask NOAH: Complementary and Alternative Medicine
1201-Geneva
www.noah-health.org
Switzerland
Association of Nurse Advocates for Childbirth Solutions 41-22-908-01-00
www.anacs.org 41-22-908-01-01 (fax)
www.icn.ch
Benchnet, the Benchmarking Exchange
Benchmarking and Best practices Network Internet Health Library
www.benchnet.com www.internethealthlibrary.com
Birthing from Within MEDLINEplus: Alternative Medicine
www.birthpower.com www.nlm.nih.gov/medlineplus
CAM on PubMed Midwives Alliance of North America
www.nlm.nih.gov/nccam/camonpubmed.html P.O. Box 6310
Charlottesville, VA 22906
Childbirth.org
www.mana.org
www.childbirth.org
National Association of Childbearing Centers
Clinical Benchmarking
www.birthcenters.org
P.O. Box 65
Glen Ellyn, IL 60138 National Center for Complementary and Alternative Medicine
800-808-3076 National Institutes of Health
630-690-7596 (fax) P.O. Box 7923
http://clinmarking.com Gaithersburg, MD 20898-7923
888-644-6226
Doulas of North America
866-464-3616 (fax)
P. O. Box 626
http://nccam.nih.gov/
Jasper, IN 47547
888-788-DONA (3662) National Institutes of Health
812-634-1494 (fax) Office of Dietary Supplements
www.dona.org http://dietary-supplements.info.nih.gov/
001-020_CH01_Lowdermilk.qxd 9/29/05 1:18 PM Page 19
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