Contemporary Maternal-Newborn Nursing

Chapter 1 Current Issues

in Maternal-Newborn Nursing

Chapter 2 Care

of the Family

in a Culturally Diverse Society

Chapter 3 Complementary

and Alternative Therapies


Current Issues

in Maternal-Newborn Nursing

Our daughter just told us

that she is 3 months pregnant

with our first grandchild.

As a labor

and delivery nurse

for 25 years,

I’ve helped

with hundreds

of births,

but it still seems magical

to me,

especially now.

I’m excited

for her

and a little worried

because I know all the risks

as well

as the joys.

She is so happy;

when I am

with her I just want

to laugh out loud.

I already know I love being a grandmother,

even though I really am too young!


Assisted reproductive technology



Birth rate 17

Certified nurse-midwife



Certified registered nurse



Client 5

Clinical nurse specialist



Evidence-based practice 20

Infant mortality rate 18

Informed consent 11

Intrauterine fetal surgery 14

Maternal mortality rate 19

Nurse practitioner



Professional nurse 8

Therapeutic insemination




1. Relate the concept

of the expert nurse

to nurses caring

for childbearing families.

2. Discuss the impact

of the self-care movement

on contemporary childbirth.

3. Compare the nursing roles available

to the maternal-newborn nurse.

4. Identify specific factors

that contribute

to a family’s value system.

5. Delineate significant legal

and ethical issues

that influence the practice

of nursing

for childbearing families.

6. Evaluate the potential impact

of some

of the special situations

in contemporary maternity care.

7. Contrast descriptive

and inferential statistics.

8. Relate the availability

of statistical data

to the formulation

of further research questions.

9. Delineate the benefits

of evidence-based nursing practice

to the client,

the institution,

and the profession

of nursing.

The practice

of most nurses is filled

with special moments,

shared experiences,



which they know they have practiced the essence

of nursing and,

in doing so,

have touched a life.

What is the essence

of nursing?

Simply stated,

nurses care

for people,


about people,

and use their expertise

to help people help themselves.


like working

with students.

I enjoy the enthusiasm they bring,

the questions they ask,

the ways they cause me

to examine my practice.

I love being a nurse.

I am passionate

about the importance


what I do,

and I feel the need

to seize every chance

to influence those


will be practicing beside me someday.

Last week was a perfect example.

I had a nursing student working

with me

in one

of our birthing rooms.

It was her first day caring

for a laboring woman,

and she was scared

and excited

at the same time.

We were taking care

of a healthy woman

who had two boys

at home

and really wanted a girl.

as labor progressed,

the student

and I worked closely together monitoring contractions,

teaching the woman

and her husband,


what we could

to ease her discomfort.

Sometimes the student

would ask

how I knew when

to do something,

a vaginal exam,

for example,

and I’d have

to think beyond “I just do”

to give her some clues.

At the birth the student stayed close

to the mother,


and helping

with breathing.

The student was excited

but felt she had an important role

to play,

and she handled it beautifully.

At the moment

of birth the student

and the dad were leaning forward watching

as the baby just slipped

into the world.

There wasn’t a sound

until the student said

in a voice filled

with awe,


it’s a girl!”

Then we all laughed

and hugged each other.

What a day-using my expertise

to help others

and helping a future nurse recognize the importance


what we do!

All nurses

who provide care

and support

to childbearing women

and their families

can make a difference.


how does this happen?

How do nurses develop expertise

and become skilled,

caring practitioners?

in her classic work,



suggested that

as nurses develop their skills

in making clinical judgments

and intervening appropriately,

they progress

through five levels

of competence.


as a novice,

the nurse progresses

to advanced beginner

and then

to competent,


and finally,

expert nurse.

in the preceding situation,

the student was clearly a novice.

Lacking experience,

the novice relies

on rules

to guide actions.

As nurses gain experience,

they begin

to draw


that experience

to view situations more holistically,

becoming increasingly aware

of subtle cues

that indicate physiologic

and psychologic changes.

Expert nurses,

like the nurse

in the preceding situation,

have a clear vision


what is possible

in a given situation.

This holistic perspective is based

on a wealth

of knowledge bred

of experience

and enables nurses

to act “intuitively”

to provide effective care.

In reality nurses’ intuition reflects their internalization

of information.

When faced

with a clinical situation,

nurses draw

almost subconsciously

on their stored knowledge

and judgment.

This intuitive perception is integral

to the “art

of nursing,”


in areas such

as maternal-newborn nursing,

where change occurs quickly

and families look

to the nurse

for help

and guidance.

Labor nurses become attuned

to a woman’s progress

or lack

of progress;

nursery nurses detect subtle changes

in their infant charges;


and postpartal nurses become adept

at assessing

and teaching.



who are cross-trained

as labor,



and postpartum


nurses become skilled

at caring

for childbearing families during all phases

of childbirth.

Thus skilled nursing practice depends

on a solid base

of knowledge

and clinical expertise delivered

in a caring,

holistic manner.

Control develops

as nurses learn

to handle their own emotions and

to master clinical situations

by making

and acting

on client care decisions.

Control issues are often difficult

for advanced beginners,


can demonstrate only marginally acceptable performance



and they may look

to expert nurses

for guidance.

As nurses provide good nursing care

and develop a knowledge base,

they gain competence.

From this competence flows credibility

as others begin

to trust

and believe

in them.


in turn become self-reliant

and gain confidence

in their judgment.

Finally a sense

of comfort develops

and nurses feel able

to predict probable outcomes.

My first pregnancy ended

in spontaneous abortion

at 8 weeks,

so this time I decided not

to tell anyone I was pregnant

until I was 3 months along.

We had just told both families the news the preceding day

when it happened again.

I began bleeding heavily,

and we rushed

to the ER.

Here I was,

a maternal-newborn nursing instructor,

and I couldn’t seem

to handle a pregnancy.

I was

in the bathroom

when I passed the fetus

into the Johnny cap.

My poor baby-so small,

maybe 3

or 4 inches long.

I began

to sob uncontrollably

as I rang

for the nurse.

I told her

what happened,

and she helped me

to bed.

My husband sat

with his arm

around me

as I cried

while the nurse took our baby out.

A few minutes later,

she came back

and said,

“I saw

on your record

that you are Catholic.

Would you

like me

to baptize your baby?”

I said,




and she left.

I’ve never forgotten


that made me feel.

She saw me

as a total person.

I’m still teaching,

and now I have two children.

Whenever I teach high-risk pregnancy,

I tell

that story

to the students.

I want them

to know

what a difference a nurse

can make.

We believe

that many nurses

who work

with childbearing families are experts:

They are sensitive,



critical thinkers.

They are technically skilled,

empowered professionals


can collaborate effectively

with others

and advocate

for those individuals

and families

who need their support.

Such nurses do make a difference

in the quality

of care

that childbearing families receive.


The scope

of practice

of maternal

and newborn nurses has changed dramatically

in the past 25 years.

Today’s maternal-newborn nurses have far broader responsibilities

and focus more

on the specific goals

of the individual childbearing woman

and her family

(Figure 1-1


Not only has maternal-newborn nursing changed,

so has the whole experience

of childbirth.

No longer do laboring women leave their partners

and family

at the labor room door

while they work

to give birth without the family’s loving presence;

no longer are newborns routinely whisked away

for a prescribed period,

to reappear magically

for feedings every 4 hours


then return

to the safe atmosphere

of a central nursery;

no longer are young siblings treated

like walking sources

of infection

that threaten every infant.

Today fathers are active participants

in the birth experience.


and friends are also often included.

Siblings are encouraged

to visit

and meet their newest family member

and may

even attend the birth.

Today the concept

of “family-centered childbirth” is accepted

and encouraged.

in addition,

new definitions

of family are evolving

as discussed

in Chapter 2.

For example,

the family

of the single mother may include her mother,


another relative,

a close friend,

or the father

of the child.

Many cultures also recognize the importance

of extended families,

where several family members often provide care

and support.

The family

can generally make choices

about many aspects

of the childbirth experience,

including the place

of birth


free-standing birthing center,

or home birth);

the primary caregiver


certified nurse-midwife,

or certified midwife);

and birth-related experiences


of childbirth preparation,


of analgesia

and anesthesia,

and position

for labor

and birth,

for example).

as recently

as the early 1990s,


who gave birth vaginally remained

in the hospital

for approximately 3 days.

This provided ample time

for nurses

to assess the family’s knowledge

and skill

and complete essential teaching.

By the mid-1990s,

in an effort

to control costs,

hospitals were routinely discharging new mothers within 12

to 24 hours

or less following birth.

For women

with supportive families,

thorough prenatal preparation,

and adequate resources

for necessary follow-up care,

this practice did not necessarily pose a problem.


because early discharge severely limits the time available

for client teaching,


with little knowledge,


or support were

at greater risk

of being inadequately prepared

to care

for themselves

and their newborn infants.


the negative impact

of this practice gained recognition nationwide.

As a result,

Congress passed the Newborns’

and Mothers’ Health Protection Act

of 1996,

which took effect

in January 1998.

This act provides

for a postpartum stay

of up

to 48 hours following vaginal birth

and up

to 96 hours following cesarean birth

at the discretion

of the mother

and her healthcare provider.


it does not contain a provision

for home care follow-up

if a new mother chooses

to leave the birthing facility earlier

than the length

of stay mandated

by the act.

Some states have developed home care provisions

that strengthen the federal legislation.

It seems likely

that home follow-up nursing care

will continue

to gain acceptance

because it is a cost-effective approach

with favorable long-term family outcomes.

In addition,


can access a variety

of community resources,

from local programs focusing

on specific topics such

as parenting

or postpartal exercise

to the widely recognized support provided

by national organizations such

as La Leche League.

for families

with access

to the Internet,

a wealth

of information

and advice is available.

For example,

the Department

of Health

and Human Services’ Office

on Women’s Health offers a wide variety

of educational resources designed

to help promote women’s health

and well-being.

Web links

to a variety

of other organizations

and consumer publications also exist.


in complementary

and alternative medicine


practices is growing nationwide

and is having an impact

on the care

of childbearing families.

In response

to this trend,

the National Institutes

of Health now has an Office

of Alternative Medicine.

Nurses caring

for childbearing families need

to recognize

that a significant percentage

of Americans are using some form

of unconventional

or alternative practice

although they may not share this information

with their healthcare provider.

Thus it is important

for nurses

to communicate a willingness

to work

with the client

to recognize

and respect these alternative approaches.

To assist nurses caring

for these childbearing families we have included a chapter-Chapter 3

-on complementary

and alternative therapies.

Many women elect

to have their pregnancy

and birth managed

by a certified nurse-midwife


a registered nurse

who is also prepared

as a midwife.


of the CNM is offered

through the American College

of Nurse-Midwives


The preparation

and role

of the CNM is described

on page 8.

Some women choose

to receive care

from a direct-entry certified midwife


even a lay midwife

(an unlicensed

or uncertified midwife

who is trained

through an informal route such

as apprenticeship

or self-study rather

than a formal educational program

[Midwives Alliance

of North America{MANA},



who complete a direct-entry midwifery education program

that meets the standards established

by ACNM may take a certification exam

to become a certified midwife


ACNM has mandated that,

by 2010,

a master’s

or doctoral degree

will be required

for entry

into clinical practice

as either a CNM

or CM



The North American Registry

of Midwives


is also a certification agency.

Midwives certified

through NARM may become midwives

through a formal educational program

at a college,


or midwifery school,


through apprenticeship

or self-study.

They are eligible

to use the credential certified professional midwife


Some women choose

to give birth

at home

although healthcare professionals do not generally recommend this approach.

The concern

of the healthcare professional is that,

in the event

of an unanticipated complication

that threatens the well-being

of the mother

or her infant,


in obtaining emergency assistance might result.

Some CNMs do attend home births;


the majority

of home births are attended

by CMs,


or lay midwives.


The self-care movement began

to emerge

in the late 1960s

as consumers sought

to understand technology

and take an interest

in their own health

and basic self-care skills.


and more people have begun

to exercise,

control their diet,

monitor their psychologic

and physiologic status,


in some cases

even do their own diagnostic tests.

They thus assume many primary care functions.


today’s healthcare consumers are requiring greater information

and accountability

from their healthcare providers.

These consumers recognize

that knowledge,


is power.

Practicing self-care-assuming responsibility

for one’s own health-often requires assertiveness

and taking an active role

in seeking necessary information.


can foster self-care

by providing information readily and

by acknowledging people’s right

to ask questions

and become actively involved

in their own care.

Maternal-newborn care offers a special opportunity

to promote active participation

in health care

because it is essentially health focused;

in most cases,

clients are well

when they enter the system.

The consumer movement

that has already influenced childbirth encourages people

to speak up

for preferences

in dealing

with healthcare providers.

Self-care has gained an

even broader appeal

in recent years

because research suggests

that it

can significantly reduce healthcare costs.

We believe

that self-care

will be a vital part

of health care

for years

to come.


self-care is not always realistic

or appropriate,


in acute emergencies,


in many situations it is appropriate.

With this

in mind,

throughout this book we have attempted

to suggest ways


which nurses might offer health education


would enable the childbearing family

to meet their own healthcare needs.

We see this

as one

of nursing’s most important functions

and one

that nurses are especially well qualified

to perform.


of our support

of self-care,

we have used the term client rather

than patient

when referring

to the childbearing woman.

The term client implies an active,


than a passive,


The client seeks assistance

from professionals

who have special skills

and knowledge

that the client does not.

The healthcare professional offers information

and suggestions

for a plan

of action regarding the client’s particular situation.

The client

can choose not

to accept the professional’s advice.


the healthcare professional cannot proceed

with the plan

of action without the client’s consent.

In this relationship,

clients assume responsibility

for their decisions.

The nursing profession has been

at the forefront

in recognizing

that people

who are able

to do so

should take an active role

in their own health care,

and the term client best fits this concept.

Nurses must understand

that it is their professional expertise

and skill

that the client is seeking.

Any attempt

to make decisions

for the client is inappropriate.


Healthcare issues are

at the top

of policy

and legislative agendas.



and quality

of health care have become the “bywords”

of the times.

In 1960,

healthcare costs

in the United States accounted

for approximately 5%

of the gross domestic product


In 2004 the healthcare share

of the GDP was 16%,

a staggering percentage.

Currently the United States spends a greater portion

of the GDP

on health

than any other major industrialized nation worldwide.

In actual dollars

in 2004 the United States spent $1.9 trillion

on health care




& Catlin,


Despite this increase

in spending,


not all pregnant women

and children

in the United States have access

to health care.

In 2005,


of people

under age 65

(41 million)

were without health insurance

(Figure 1-2



with incomes below

or near the poverty level were significantly more likely

to be uninsured,

as were people

of Hispanic origin

(Cohen & Martinez,


For people living

in poverty,

Medicaid is the most prevalent form

of insurance.

Together Medicaid,

the State Children’s Health Insurance Program


(a federally funded program

to provide states

with funds

for low-income,

uninsured children),

and Medicare account

for one third

of healthcare spending

as shown

in Figure 1-3



for Medicare

and Medicaid Services



for women

who become pregnant,

early prenatal care is one

of the most important approaches available

to reduce adverse pregnancy outcomes.

In 2003,


of pregnant women

in the United States began prenatal care

in the first trimester.


these percentages vary significantly

among groups,

with black,


and Native American women less likely

to receive early

and adequate prenatal care

than white

and Asian women

(National Center

for Health Statistics



The United States spends more per capita

than any other country

in the world

on health care;



with other industrialized nations,

the United States has higher infant mortality rates,

similar life expectancy,

and less access

to care.

Many people

who have insurance fear changing

or losing jobs

because they may lose healthcare benefits

and access

to insurance.

They may be denied insurance

in the future because

of preexisting conditions.

The increase

in serious,

debilitating illnesses,



and tuberculosis,


in chronic illnesses,


as diabetes

and hypertension,

makes this problem

of “job lock”

and lack

of transferability

of insurance benefits

even more significant.

For some uninsured people,

the only access

to the healthcare system is an emergency department.

This inappropriate use

of expensive services

for basic primary care is both an access

and a cost problem.

since 1998 the percentage

of people

in the United States covered

by employment-based health insurance has stayed

between 69%

and 73%,

although the percentage decreased

in 2002

and 2003.


little actual change occurred

in the percentage

of those uninsured because

of the increase

in the percentage

of people served

by Medicaid




of these people are enrolled

in some type

of managed care organization because,

in an effort

to curtail costs,

many employers have moved

from fee-for-service coverage

to some form

of managed care.

Thus managed care is now the dominant form

of healthcare delivery

in the United States.

The move

toward managed care has sparked concerns

about the quality

of health care.

Because a fee-for-service model allows the consumer

to register dissatisfaction

by choosing

to seek care elsewhere,

quality is a high priority

among fee-for-service providers.

A managed care model,

in contrast,

limits consumer choice and,

in turn,

potentially affects quality.

Establishing managed care’s effects

on quality poses a problem because

in the US system,

quality indicators such

as outcomes

of care usually have not been well determined.

An outcome-based system is essential


there is

to be comprehensive healthcare reform.

Changing the current system requires a new way

of thinking

and providing services.

Primary healthcare services

should be the base


which all other secondary

and tertiary services are built.


in the United States the opposite is still the case.

The system emphasizes high-technology care rather

than prevention.



and mortality

from disease are reduced significantly

when people use preventive health services.

There are some areas

of improvement.

For example,

between 1990

and 2003,

the percentage

of pregnant women

who received prenatal care increased

from 76%

to 84%.


between 1987

and 2003,

the percentage

of women age 40

and over

who had had a mammogram

in the preceding 2 years more

than doubled,


from 29%

to 69.5%



The new Health Insurance Portability

and Accountability Act


of 1996,

which was fully implemented

in 2002,

has also had an impact

on health care.

HIPAA has two areas

of focus:

it protects the health insurance coverage

of employees

and their family

if they lose a job

or change jobs.

It also addresses the privacy

and security

of health information

and requires

that national standards be established

for the electronic transmission

of healthcare data.

The privacy rule is the federal regulation developed

to meet HIPAA requirements.

It defines the policies

and procedures

to be followed

to safeguard an individual’s protected health information.

It also guarantees people access

to their medical records

and provides recourse

for them

if their medical privacy is violated.

HIPAA regulations have caused healthcare facilities

to take a wide variety

of actions

to ensure client/patient privacy.

It has also empowered individuals

by giving them access

to information

about their health care.

Academic programs

that prepare nurses,


and other healthcare professionals have had

to develop tools

and resources

to ensure

that their students understand privacy requirements

and comply

with them.

Providing all segments

of the population

with access

to primary health care

should be the chief criterion

for meaningful reform

of the US healthcare system.

This includes a focus

on health promotion,


and individual responsibility

for one’s own health.

In this model,

secondary healthcare services

would use a smaller proportion

of the healthcare dollar.

The current emphasis

on healthcare reform has yielded an unexpected benefit:

Many healthcare providers

and consumers have become more aware

of the vitally important role nurses play

in providing excellent care

to clients

and families.

The emerging shift

in the US healthcare system presents a significant opportunity

for the nursing profession.


this opportunity

for responding


and creating change

in nursing

and healthcare delivery requires a new way

of thinking.

Nurses must clearly articulate their role

in the changing environment.

They must define

and differentiate practice roles

and the educational preparation required

for those new roles,


in community-based nursing practice

and advanced practice roles such

as nurse practitioners


and CNMs.

Nurses must delineate roles

of caregiver

and care manager.

Nurses must also assume greater roles

in promoting health

and preventing disease.

In reality,

in many settings nurses assume the primary responsibility

for preventive healthcare services

and screening programs.

Healthcare reform is influencing women’s health

and maternal-newborn nursing.

Several factors,

including demographic changes,

the nationally recognized need

to improve access

to care,

public demand

for more effective healthcare options,

new research findings,

and women’s preferences

for health care,

are contributing

to changes

in the field.

Changes are predicted

in clinical procedures,

provider roles,

care settings,

and financing

of care.

As access

to health care

and the need

to control costs increase,


will the need for,

and utilization of,


in advanced practice roles.


The US population has a varied mix

of cultural groups,

with ever-increasing diversity.


than one third

of all children less

than 20 years

of age are

from families

of minority populations.

Culture develops

from socially learned beliefs,



and integrated patterns

of behavior

that are characteristic

of the family,

cultural group,

and community.

The cultural background

and values

of childbearing families are often quite different

from those

of the nurse.

Specific elements

that contribute

to a family’s value system include the following:

* Religion

and social beliefs

* Presence

and influence

of the extended family,

as well

as socialization within the ethnic group

* Communication patterns

* Beliefs

and understanding

about the concepts

of health

and illness

* Permissible physical contact

with strangers

* Education

Specific differences

in beliefs

between families

and healthcare providers are common

in the following areas:

* Help-seeking behaviors

* Pregnancy

and childbirth practices

* Causes

of diseases

or illnesses

* Death

and dying

* Caretaking

and caregiving

* Childrearing practices

These elements

in differing degrees influence the cultural beliefs

and values

of an ethnic group,

making the group unique.

Misunderstandings may occur

when the healthcare professional

and the family come

from different cultural groups.

In addition,

past experiences

with care may have made the family angry

or suspicious

of providers.

Nurses need

to be able

to recognize,


and respond

to ethnic diversity

in a way

that leads

to a mutually desirable outcome.

The nurse needs

to identify culturally relevant facts

about the client

to provide culturally appropriate

and competent care.

developing cultural competence

values conflicts


can occur

with a childbearing woman

and her family

when traditional rituals

and practices

of the family’s elders do not conform

with current healthcare practices.

Nurses need

to be sensitive

to the potential implications

for the woman’s health

and that

of her newborn,

especially after they are discharged home.

When cultural values are not part

of the nursing care plan,

a woman

and her family may be forced

to decide whether the family’s beliefs

should take priority

over the healthcare professional’s guidance.

when the family’s cultural values are incorporated

into the care plan,

the family is more likely

to accept

and comply

with the needed care,


in the home care setting.

It is important

for nurses

to avoid imposing personal cultural values

on the women

and families

in their care.

By learning

about the values

of the different ethnic groups

in the community-their religious beliefs

that have an impact

on healthcare practices,

their beliefs

about common illnesses,

and their specific healing practices-nurses

can develop an individualized nursing care plan

for each childbearing woman

and her family.


of the importance

of culturally competent care,

this topic is discussed

in more depth

in Chapter 2

and throughout the book

as well.



as a man,


don’t always find it easy

to be a labor

and delivery nurse.

I have three children

of my own

and attended all their births.

It meant a lot

to me

to be there,

and I

like helping others

to have good childbirth experiences,



don’t fit some people’s image

of a nurse;

so they refer

to me

as a “male nurse”

as opposed

to a real nurse,

and they ask

why I didn’t go

into medicine instead.

Why can’t they understand

that I’m a nurse

because it’s

what I really want

to be-and I’m darned good

at it,


More men are choosing nursing now,

and I think that

will help.

I hope

to see the day

when we

don’t have “female doctors”

and “male nurses,”

but doctors

and nurses,


Maternal-newborn nurses are found

in the maternity departments

of acute care facilities,

in physicians’ offices,

in clinics,

in college health services,

in school-based programs dealing

with sex education

or adolescent pregnancies,

in community health services,


in any other setting

where a client has a need

for maternity care.

The depth

of nursing involvement

in various settings is determined

by the qualifications

and the role

or function

of the nurse employed.

Many different titles have evolved

to describe the professional requirements

of the nurse

in various maternity care roles.

These titles include the following:

* A professional nurse is a graduate

of an accredited basic program

in nursing

who has successfully completed the nursing examination


and is currently licensed

as a registered nurse


Professional nurses are typically educated

as generalists.

* A certified registered nurse


has shown expertise

in a particular field

of nursing such

as labor

and delivery

by taking a national certification examination.

* A nurse practitioner


is a professional nurse

who has received specialized education

in either a master’s degree program

or a continuing education program

and thus

can function

in an expanded role.

Nurse practitioners often provide ambulatory care services

to the expectant family

(women’s health nurse practitioner,

family nurse practitioner);

some NPs also function

in acute care settings

(neonatal nurse practitioner,

perinatal nurse practitioner).

NPs focus

on physical

and psychosocial assessment,

including health history,

physical examination,

and certain diagnostic tests

and procedures.

The nurse practitioner makes clinical judgments

and begins appropriate treatments,

seeking physician consultation

when necessary.

The emerging emphasis

on community-based care has greatly increased opportunities

for NPs.

* A clinical nurse specialist


is a professional nurse

with a master’s degree

who has additional specialized knowledge

and competence

in a specific clinical area.

CNSs assume a leadership role within their specialty

and work

to improve client care both directly

and indirectly.

* A certified nurse-midwife


is educated

in the two disciplines

of nursing

and midwifery

and is certified

by the American College

of Nurse-Midwives


The certified nurse-midwife is prepared

to manage independently the care

of women

at low risk

for complications during pregnancy

and birth

and the care

of normal newborns

(Figure 1-4


In 2001 the American College

of Obstetricians

and Gynecologists


and the ACNM issued a joint statement describing the independent,


and interdependent responsibilities

of both groups,

namely obstetricians/gynecologists

and certified nurse-midwives/certified midwives.

This agreement affirms

that the “quality

of care is enhanced

by the interdependent practice

of the obstetrician/gynecologist

and the certified nurse-midwife/certified midwife working

in a relationship

of mutual respect,


and professional responsibility.”

This agreement does not require the physical presence

of an OB/GYN physician

but does include the use

of mutually agreed-upon written medical guidelines/protocols



The term advanced practice nurse is used

to describe nurses who,

by education

and practice,


in an expanded nursing role.

The term,

often used

in a legal sense

in state nurse practice acts,

most frequently applies

to NPs,



(certified registered nurse anesthetists),

and CNMs.

As NPs assume a more prominent role

in providing care,

the distinctions

between the roles

of the nurse practitioner

and the clinical nurse specialist are beginning

to blur

and these roles may ultimately merge.

Collaborative Practice

Managed care has led

to a rethinking

of care delivery.

One approach

that is becoming increasingly popular is collaborative practice.

Collaborative practice is a comprehensive model

of health care

that uses a multidisciplinary team

of health professionals

to provide cost-effective,

high-quality care.

In maternal-newborn settings,

the team generally includes CNMs

and NPs

in practice

with physicians

(often obstetricians

or family practice physicians)

and may include other health professionals,


as lactation consultants,

social workers,

or CNSs

(Figure 1-5


Successful teams have certain characteristics

(Simpson & Knox,


* They have established consensus

about their mission

and vision,

their goals,

and their objectives

and strategies.

* They recognize,


and value the unique contributions

of each team member.

* They share a sense

of mutual accountability-the team,

not an individual,

is responsible

for success

or failure.

* They are part

of an organization

that has strong,

well-delineated performance standards

and expectations.

* They have established effective communication.

in a successful team,

each individual has autonomy

but functions within a clearly defined scope

of practice.

In such a collaborative approach,

no single profession “owns the client.”


the team seeks

to empower clients

and families

and include them

as partners

in their care and

in decision making.

Community-Based Nursing Care

Many advocates

of a new direction

for health care support the increasing emphasis

on primary care.

Primary care includes a focus

on health promotion,

illness prevention,

and individual responsibility

for one’s own health.

These services are best provided

in community-based settings.

Third-party payers

and managed care organizations are beginning

to recognize the importance

of primary care

in containing costs

and maintaining health.

Community-based health services providing primary care

and some secondary care

will be available

in schools,





transitional care programs,

and other ambulatory settings.

The growth

and diversity

of managed care plans offer both opportunities

and challenges

for women’s health care.

The potential exists

for managed care organizations

to work

with consumers

to provide a model

for coordinated

and comprehensive well-woman care

that includes improved screening

and preventive services.

One challenge managed care organizations

will face is how

to relate

to essential community providers

of care-organizations such

as family planning clinics

or women’s health centers-that offer a unique service

or serve groups

of women

with special needs


disabled women,


or racial minorities).

Community-based care remains an essential element

of health care

for uninsured

and underinsured individuals

as well


for those individuals

who benefit

from programs such

as Medicare

or state-sponsored health-related programs.


of these programs,


as those offered

through public health departments,

are broad based;



as parenting classes

for adolescents,

are geared

to the needs

of a specific population.

Community-based care is also part

of a trend initiated

by consumers,

who are asking

for a “seamless” system

of family-centered,


coordinated health care,

health education,

and social services.

This seamless system requires coordination

as clients move

from primary care services

to acute care facilities


then back

into the community.

The shortened length

of hospital stays further mandates the need

for coordination

of services.


can assume this care management role

and perform an important service

for individuals

and families.

Maternal-newborn nurses are especially sensitive

to these changes

in healthcare delivery

because the vast majority

of health care provided

to childbearing families takes place outside hospitals

in clinics,


and community-based organizations.

In addition,

maternal-newborn nurses offer specialized services such

as childbirth preparation classes

or postpartal exercise classes.

In essence,

we are already experts

at providing community-based nursing care.


it is important

that we remain knowledgeable

about current practices

and trends

and open

to new approaches

to meet the needs

of women

and children.

HOME CARE The provision

of health care

in the home is emerging

as an especially important dimension

of community-based nursing care.

The shortened length

of hospital stays has resulted

in the discharge

of individuals

who still require support,


and teaching.

Home care

can help fill this gap.


home care also enables individuals

to remain

at home

with conditions

that formerly

would have required hospitalization.

Nurses are the major providers

of home care services.

Home care nurses perform direct nursing care

and also supervise unlicensed assistive personnel

who provide less skilled levels

of service.

In a home setting,


can use their skills

in assessment,




problem solving,

and organization

to meet the needs

of childbearing families.

They also play a major role

in coordinating services

from other providers,


as physical therapists

or lactation consultants.


and newborn home visits are becoming a recognized way

of ensuring

that childbearing families make a satisfactory transition

from the hospital

or birthing center

to the home.

We see this trend

as positive

and hope

that this method

of meeting the needs

of childbearing families becomes standard practice.

Chapter 36 discusses home care

in more detail

and provides guidance

about making a home visit.

In addition,

throughout the text we have provided information


how home care

can meet the needs

of women

with health problems such

as diabetes

or preterm labor,

which put them

at risk during pregnancy.

We believe

that home care offers nurses the opportunity

to function

in an autonomous role

and make a significant difference

for individuals

and families.



Professional nursing practice requires full understanding

of practice standards,


or agency policies,

and local,


and federal laws.

Professional practice also requires an understanding

of the ethical implications

of those standards,


and laws

that impact care,

care providers,

and care recipients.

Every professional nurse is responsible

for obtaining

and maintaining current information regarding ethics

and laws related

to nursing practice

and health care.


of Practice

State nurse practice acts protect the public

by broadly defining the legal scope

of practice within

which every nurse must function and

by excluding untrained

or unlicensed individuals

from practicing nursing.

Although some state practice acts continue

to limit nursing practice

to the traditional responsibilities

of providing client care related

to health maintenance

and disease prevention,

most state practice acts cover expanded practice roles

that include collaboration

with other professionals

in planning

and providing care,


and prescriptive privilege,

and the delegation

of client care tasks

to other specified licensed

and unlicensed personnel.

Specified care activities

for certified nurse-midwives

and women’s health,


or neonatal nurse practitioners may include diagnosis

and prenatal management

of uncomplicated pregnancies

(CNMs may also manage births)

and prescribing

and dispensing medications using protocols

in specified circumstances.

A nurse must function within the scope

of practice

or risk being accused

of practicing medicine without a license.

Correctly interpreting

and understanding state practice acts enables the nurse

to provide safe care within the limits

of nursing practice.

State boards

of nursing may provide official interpretation

of practice acts

when the limits are not clear.

On occasion hospital policy may conflict

with a state’s nurse practice act.

It is important

to recognize

that hospital

or agency policy may restrict the scope

of practice specified

in a state practice act,

but such policy cannot legally expand the scope

of practice beyond the limits stated

in the practice act.

Nurse practice acts are subject

to change.

One component

of professional nursing practice is the responsibility

of each nurse

to remain up-to-date regarding scope

of practice

and even

to participate actively

in promoting appropriate changes.

Nursing Negligence

Negligence is defined

as omitting

or committing an act

that a reasonably prudent person

would not omit

or commit

under the same

or similar circumstances.

Negligence consists

of four elements:

1. There was a duty

to provide care.

2. The duty was breached.

3. Injury occurred.

4. The breach

of duty caused the injury

(proximate cause).

Duty may be breached

by omission-failing

to give a medication,


to assess properly,


to notify a physician

of a change

in a laboring woman’s condition,

and so on.

Duty may also be breached

by commission-giving the wrong medication,

placing an infant

in the wrong crib,

and so on.

The injury

that results may be physical

or mental


and suffering).

In determining whether nursing negligence occurred,

the care

that was given is compared

with the standard

of care.

If the standard was not met,

negligence occurred.


of Nursing Care


of care establish minimum criteria

for competent,

proficient delivery

of nursing care.

Such standards are designed

to protect the public

and are used

to judge the quality

of care provided.

Legal interpretation

of actions within standards

of care is based


what a reasonably prudent nurse

with similar education

and experience

would do

in similar circumstances.


of CARE STANDARDS Written standards

of care are provided

by a number

of different sources.

The American Nurses Association


has published standards

of professional practice

since 1950.

In 1973,

the ANA Congress

for Nursing Practice began

to write generic standards

for all nurses

in all settings.

In addition,

the ANA Divisions

of Practice have published standards

that include nursing practice

for maternal-child health.

The Council

of Perinatal Nurses has published standards

for perinatal nursing.

Other specialty organizations,


as the Association

of Women’s Health,


and Neonatal Nurses


the Association

of Operating Room Nurses


and the National Association

of Neonatal Nurses


have developed standards

of specialty practice.

Agency policies,


and protocols also provide appropriate guidelines

for care standards.

The Joint Commission

on Accreditation

of Healthcare Organizations


a private,

nongovernmental agency

that audits the operation

of hospitals

and healthcare facilities,

has also contributed

to the development

of nursing standards.

Agency policies,


and protocols also provide appropriate guidelines

for care standards.

For example,

clinical practice guidelines

and clinical pathways are comprehensive interdisciplinary care plans

for a specific condition

that describe the sequence

and timing

of interventions


should result

in expected client outcomes.

Clinical practice guidelines

or clinical pathways are adopted within a healthcare setting

to reduce variation

in care management,

to limit costs

of care,


to evaluate the effectiveness

of care.

Some standards carry the force

of law;


although not legally based,

still carry important legal significance.

Any nurse

who fails

to meet appropriate standards

of care invites allegations

of negligence

or malpractice.

(Malpractice is negligent action

of a professional person.)


any nurse

who practices within the guidelines established

by agency,


or national standards is assured

that clients are provided

with competent nursing care,


in turn,

diminishes the potential

for litigation.



of care are based

on a legal model rather than

on ethics.


they incorporate important ethical components

that extend the narrow legal interpretation

of the term standard.


there is a great deal

of interplay

between the two disciplines,

each has a different perspective.

Law is based primarily

on a rights model

that establishes rules

of conduct

to define relationships

among individuals.

Law may also define relationships

to impersonal entities

like formal organizations,


or hospitals.


in contrast,

is based

on a responsibility

or duty model

that considers a wider range

of factors

than the rights model

of law.

Ethics incorporates factors such

as risks,


other relationships,


and the needs

and abilities

of persons affected


and affecting decisions.


and ethics are interrelated;

they share a similar decision process

and standards.

Both disciplines incorporate fact-finding,

conflict negotiation,


of related issues

and values,

and the application

of resolutions

of particular cases

in decision making.

Professional nurses must consider the ethical implications

of legal decisions

and the legal implications

of ethical decisions.

Understanding the distinctions

among medical

or healthcare decisions,

legal decisions,

and ethical decisions is important.

Consider the case


which parents

from a culture unfamiliar

to the nurse refuse surgery

for their newborn based

on a deeply held spiritual belief

that intentional cutting

of a body

will result

in spiritual death.

Such a decision

to forgo surgery may be viewed

as negligent

in the eyes

of the law,


and inappropriate

from a medical perspective,

yet fully justifiable ethically.


legally sanctioned maintenance

of life support

for a severely damaged newborn

with little hope

for meaningful existence may remain a medically viable alternative,


to many it is not ethically justifiable.

Recognizing the type

of decision

to be made often helps measure the worth

and outcome

of a decision more appropriately.

Clients’ Rights


and ethics impact all

of nursing practice,

and several topics have specific implications

for maternal-child nursing practice.

Clients’ rights encompass such topics

as informed consent,


and confidentiality.


on the Accreditation

of Healthcare Organizations



has identified patient safety

as an important responsibility

of healthcare providers

and established the following patient safety goals

as requirements

for accreditation

in 2007.

1. Improve the accuracy

of patient identification.

2. Improve the effectiveness

of communication

among caregivers.

3. Improve the safety

of using medications.

4. Reduce the risk

of healthcare-associated infections.

5. Accurately

and completely reconcile medications

across the continuum

of care.

6. Reduce the risk

of patient harm resulting

from falls.

7. Reduce the risk

of influenza

and pneumococcal disease

in institutionalized older adults.

8. Reduce the risk

of surgical fires.

9. Implementation

of applicable National Patient Safety Goals

and associated requirements

by components

and practitioner sites.

10. Encourage patients’ active involvement

in their own care

as a patient safety strategy.

11. Prevent healthcare-associated pressure ulcers

(decubitus ulcers).

12. The organization identifies safety risks inherent

in its patient population.

INFORMED CONSENT Informed consent is a legal concept designed

to allow clients

to make intelligent decisions regarding their own health care.

Informed consent means

that a client,

or a legally designated decision maker,

has granted permission

for a specific treatment

or procedure based

on full information about

that specific treatment

or procedure

as it relates


that client

under the specific circumstances

of the permission.

Although this policy is usually enforced

for such major procedures

as surgery

or regional anesthesia,

it pertains

to any nursing,


or surgical intervention.

To touch a person without consent


in an emergency)

constitutes battery.

Several elements must be addressed

to ensure

that the client has given informed consent.

The information must be clearly

and concisely presented

in a manner understandable

to the client

and must include risks

and benefits,

the probability

of success,

and significant treatment alternatives.

The client also needs

to be told the consequences

of receiving no treatment

or procedure.


the client must be told

of the right

to refuse a specific treatment

or procedure.

Each client

should be told

that refusing the specified treatment

or procedure does not result

in the withdrawal

of all support

or care.

The individual

who is ultimately responsible

for the treatment

or procedure

should provide the information necessary

to obtain informed consent.

In most instances,

this is a physician.

In such cases,

the nurse’s role may be

to witness the client’s signature giving consent.

A nurse

who knows the client

and the procedure may certainly help the physician obtain the client’s consent

by clarifying the information the physician provides.

It is also part

of the nurse’s role

to determine

that the client understands the information

before making a decision.




and medications

that alter consciousness may influence an individual’s ability

to give informed consent.

An oral consent is legal

but written consent is easier

to defend

in a court

of law.

Society grants parents the authority

and responsibility

to give consent

for their minor children.

Parents are presumed

to possess

what a child lacks

in maturity,


and capacity

for judgment

in life’s difficult decisions.

Although the age

of majority is 18 years

in most states,


in certain states require

that nurses be aware

of the law

in the state

where they practice.


under 18

or 21 years

of age,


on state law,

can legally give informed consent

in the following circumstances:

* When they are minor parents

of the infant

or child client

* When they are emancipated minors

(self-supporting adolescents

under 18 years

of age,

not subject

to parental control)

* When they are adolescents

between 16

and 18 years

of age seeking birth control,

mental health counseling,

or substance abuse treatment

(Dickey & Deatrick,


Mature minors


and 15-year-old adolescents

who are able

to understand treatment risks)

can give consent

for treatment

or refuse treatment

in some states.

Special problems

can occur

in maternity nursing

when a minor gives birth.

It is possible,

depending upon state law,

that a minor may be able

to consent

to treatment

for her infant

but not

for herself.

In some states,


a pregnant teenager is considered an emancipated minor

and may therefore give consent

for herself

as well.


some states require a married woman

to obtain the consent

of her spouse

when a procedure involves sterilization

or threatens the life

of a fetus.

Although childbearing women sign a general consent form

on admission

to an agency,

separate informed consent is often required

for surgery,

cesarean birth,

the administration

of anesthesia,

tubal ligation,

or participation

in research.


of a treatment,


or procedure after appropriate information also requires

that a client sign a form

to release the physician

and agency

from liability.

Jehovah’s Witnesses’ refusal

of blood transfusion

or Rh immune globulin is an example

of such refusal.

Nurses are responsible

for educating clients

about any nursing care provided.

Before each nursing intervention,

the maternal-child nurse lets the individual and/or family know what

to expect,

thus ensuring cooperation

and obtaining consent.


the nurse documents the teaching

and the learning outcomes

in the person’s record.

The importance

of clear,


and complete nursing records cannot be overemphasized.

These records are evidence

that the nurse obtained consent,

performed prescribed treatments,

reported important observations

to the appropriate staff,

and adhered

to acceptable standards

of care.


to PRIVACY The right

to privacy is the right

of a person

to keep his

or her person

and property free

from public scrutiny.

Maternity nurses need

to remember

that this includes avoiding unnecessary exposure

of the childbearing woman’s body.

In the context

of health care,

the right

to privacy dictates

that only those responsible

for a client’s care

should examine the client

or discuss the client’s case.

Most states have recognized the right

to privacy

through statutory

or common law,

and some states have written

that right

into their constitution.

The ANA,

the National League

for Nursing


and JCAHO have adopted professional standards protecting clients’ privacy.

Healthcare agencies

should also have written policies dealing

with client privacy.


discussed previously,

also has a provision

to guarantee the security

and privacy

of health information.



and policies

about privacy specify

that information

about clients’ treatment,


and prognosis

can be shared only

by the health professionals responsible

for their care.


for the release

of any client information

should be obtained

from competent clients

or their surrogate decision maker.

Although it may be legal

to reveal vital statistics such

as name,



and prognosis,

such information is often withheld because

of ethical considerations.

The client

should be consulted regarding

what information may be released and

to whom.

When a client is a celebrity

or is considered newsworthy,

inquiries may be best handled

by the public relations department

of the agency.

CONFIDENTIALITY Given the highly personal

and intimate information requested

of clients,

the need

for maintaining confidentiality is extremely crucial

for the development

of trust

in the relationship

between client

and provider.

Privileged communications exist

between client

and physician,


and attorney,


and wife,

and clergy

and those

who seek their counsel.

In some states,


of privilege also protect nurses.


should become well informed

about privileged communication laws

in their state.

A client may waive the right

to confidentiality

of medical records

by action

or words.

For example,

if a childbearing woman sues a physician,


or other care provider,

she waives the right

to confidentiality

of the medical record

because the record becomes a source

of evidence.

Clients commonly consent

to disclose information

to insurance companies or

to their employers.


of medical records has created a greater concern

for the integrity

of records

and the potential invasion

of privacy.

in some instances,

the public good takes precedence

over an individual’s right

to privacy.

For example,

state laws require

that care providers report gunshot wounds,

child abuse,

elder abuse,

and some communicable diseases.

The Federal Patient Self-Determination Act requires all healthcare institutions

that are reimbursed

by Medicare

or Medicaid

to provide all hospitalized individuals

with written information

about their rights,

which include expressing a preference

for treatment options

and making advance directives

(writing a living will

or authorizing a durable power

of attorney

for healthcare decisions

on the individual’s behalf).

This often comes

as a surprise

to young women

and couples

of childbearing age

who may have no experience

of hospitals.


with an advance directive

in place,

a childbearing woman

can be certain that,


if she becomes incompetent,


can retain her autonomy

about healthcare decisions.

Nurses often discuss these issues

with clients

and their families


can help them explore their beliefs

and values

about treatment options

and dying.


Breaching confidentiality is a potential problem

for pregnant adolescents,

who are just learning whom they

can trust

in the healthcare system.

Make sure you openly discuss the limits

of confidentiality

for such things

as mandatory reporting requirements

with the client

and family.

Inadvertent disclosure

of personal information may lead

to psychologic,


or physical harm

for some clients.

Ethical Decision Making


and bioethical literature are filled

with examples

of ethical decision-making models

and frameworks.

Decision-making models help nurses

and other care providers confront seemingly unresolvable conflicts

among the rights,





and individuals impacted

by the ethical dilemmas

of practice.

There are six critical components

of ethical decision making;

they are very similar

to the components

of the nursing process.

1. Establish a means

of determining

who is involved

in the dilemma,

who is involved

in the decision,



will be affected

by the outcome

of the decision.

This data-gathering step allows the nurse

to identify

and define the issue

and determine

who owns the problem,

the information,

the decision,

and the consequences

of it.

2. Establish a mechanism

for obtaining all the information relevant

to the conflict,

including data related

to diagnosis,


treatment options,

available health care,

and psychosocial,



and other appropriate resources.

3. Formulate a plan

to outline all potential options

and the consequences

of each option.

Be sure

that opposing viewpoints are presented

and considered.

Set individual values aside during this phase

to encourage divergent views.

4. In the conflict resolution process

that follows,

review driving

and restraining forces,

assess risks

and benefits,

and assess the likelihood

of a successful outcome

with each option.

At this stage,

be sure

that the moral values

of everyone involved are addressed.

In addition,

review peripheral issues-such

as the possible impact

on other individuals

or systems related

to the decision,


in client condition,

pertinent laws,

or new information-within the context

of general

and individual moral principles.

5. Select

and act

on a plan

to resolve the conflict.

Before acting

on the resolution,


who is ultimately responsible

for the decision,

who is most impacted

by the outcome,

and whether consensus is required.

6. Evaluate the resolution,

its consequences,

and the decision process itself.

This step is critically important

to avoid making similar decisions

in isolation.

Ethical decisions

in maternal-child nursing are often complicated

by moral obligations

to more

than one client.

Straightforward solutions

to the ethical dilemmas nurses encounter

in caring

for childbearing families are often,

quite simply,

not available.

By using a formal decision-making structure,

nurses may,


increase the likelihood

of addressing multiple needs

in complex care situations

in an ethically appropriate

and legal manner.



Maternity care is fraught

with unique circumstances


which an ethical dilemma may arise.

These include situations

of maternal-fetal conflict,

issues related

to termination

of pregnancy,


and fetal research,

reproductive assistance,

and cord blood banking.


the use

of data

from the Human Genome Project may give rise

to ethical challenges.

Maternal-Fetal Conflict

until fairly recently,

the fetus was viewed legally

as a nonperson.


and fetus were viewed

as one complex client-the pregnant woman-of

which the fetus was an essential part.



in technology have permitted the physician

to treat the fetus

and monitor fetal development.

The fetus is increasingly viewed

as a client separate

from the mother,

although treatment

of the fetus necessarily involves the mother.

This type

of approach,

by nature adversarial,


to emphasize the divergent interests

of the mother

and her fetus rather

than focus

on their shared interests.

This focus

on the fetus intensified

in 2002

when President George W. Bush announced

that “unborn children”

would qualify

for government healthcare benefits.

The move was designed

to promote prenatal care,

but it represented the first time

that any US federal policy had defined childhood

as starting

at conception.

Most women are strongly motivated

to protect the health

and well-being

of their fetus.

In some instances,


women have refused interventions

on behalf

of the fetus,

and forced interventions have occurred.

These include forced cesarean birth,


of mothers

who practice high-risk behaviors such

as substance abuse

to enter treatment,


perhaps most controversial,

mandating experimental

in utero therapy

or surgery

in an attempt

to correct a specific birth defect.

These interventions infringe

on the autonomy

of the mother.

They may also be detrimental

to the baby if,

as a result,

maternal bonding is hindered,

the mother is afraid

to seek prenatal care,

or the mother is herself harmed

by the actions taken



These forced interventions raise two thorny questions:


What practices

should be monitored?




will determine

when the behaviors pose such a risk

to the fetus

that the courts

should intervene?

Attempts have also been made

to criminalize the behavior

of women

who fail

to follow a physician’s advice


who engage

in behaviors

that are considered harmful

to the fetus.

For example,

in 2003 a woman

in Great Falls,

New York,

was prosecuted

for child endangerment

when her son tested positive

for alcohol

at birth.

Her conviction was successfully appealed.

In 1999,

in South Carolina a 22-year-old homeless woman,

who used cocaine regularly during her pregnancy

and subsequently gave birth

to a stillborn infant,

became the first woman

in the United States

to be convicted

of homicide because

of her behavior during her pregnancy.

She was sentenced

to 12 years

in prison.

The South Carolina Supreme Court upheld the conviction

and the US Supreme Court declined

to hear the case



The American College

of Obstetricians

and Gynecologists



and the American Academy

of Pediatrics



on Bioethics


both affirm the fundamental right

of pregnant women

to make informed,

uncoerced decisions

about medical interventions.


in 2005 ACOG’s Committee

on Ethics took a direct stand

against coercive

and punitive approaches

to the maternal-fetal relationship,

citing the following “overwhelming rationale

for avoiding such approaches.

1. Coercive

and punitive legal approaches

to pregnant women

who refuse medical advice fail

to recognize

that all competent adults are entitled

to informed consent

and bodily integrity.(

2. Court-ordered interventions

in cases

of informed refusal,

as well

as punishment

of pregnant women

for their behavior

that may put a fetus

at risk,

neglect the fact

that medical knowledge

and predictions

of outcomes

in obstetrics have limitations.(

3. Coercive

and punitive policies treat medical problems such

as addiction

and psychiatric illness


if they were moral failings.(

4. Coercive

and punitive policies are potentially counterproductive


that they are likely

to discourage prenatal care

and successful treatment,

adversely affect infant mortality rates,

and undermine the physician-patient relationship.(

5. Coercive

and punitive policies directed

toward pregnant women unjustly single out the most vulnerable women.(

6. Coercive

and punitive policies create the potential

for criminalization

of many types

of otherwise legal maternal behavior”



pp. 6-9).


and AAP recognize

that cases

of maternal-fetal conflict involve two clients,


of whom deserve respect

and treatment.

Such cases are best resolved

by using internal hospital mechanisms including counseling,

the intervention

of specialists,

and consultation

with an institutional ethics committee.

Court intervention

should be considered a last resort,

appropriate only

in extraordinary circumstances.


since the 1973 Supreme Court decision

in Roe v.


abortion has been legal

in the United States.


can be performed

until the period

of viability,


which abortion is permissible only

when the life

or health

of the mother is threatened.

Before viability,

the mother’s rights are paramount;

after viability,

the rights

of the fetus take precedence.

Personal beliefs,

cultural norms,

life experiences,

and religious convictions shape people’s attitudes

about abortion.

Ethicists have thoughtfully

and thoroughly argued positions supporting both sides

of the question.


few issues spark the intensity

of response seen

when the issue

of abortion is raised.

at present,


about abortion are made

by a woman

and her physician.


(and other caregivers)

have the right

to refuse

to assist

with the procedure

if abortion is contrary

to their moral

and ethical beliefs.


if a nurse works

in an institution

where abortions may be performed,

the nurse may be dismissed

for refusing.

To avoid being placed

in a situation contrary

to their values

and beliefs,


should determine the philosophy

and practices

of an institution

before going

to work there.

A nurse

who refuses

to participate

in an abortion because

of moral

or ethical beliefs does have a responsibility

to ensure

that someone

with similar qualifications is able

to provide appropriate care

for the client.

Clients may never be abandoned,


of the nurse’s beliefs.

Fetal Research


with fetal tissue has been responsible

for remarkable advances

in the care

and treatment

of fetuses

with health problems

and advances

in the treatment

of progressive,

debilitating adult diseases such

as Parkinson disease,

Alzheimer disease,

and DiGeorge syndrome.

Therapeutic research

with living fetuses has been instrumental

in the treatment

of Rh-sensitized infants,

the evaluation

of lung maturity using the lecithin/sphingomyelin ratio,

and the treatment

of pulmonary immaturity

in the newborn.

Because it is aimed

at treating a fetal condition,

therapeutic fetal research raises fewer ethical questions

than does nontherapeutic fetal research.

To be approved,

nontherapeutic research requires

that the risk

to the fetus be minimal,

that the knowledge

to be gained be important,


that the information be unobtainable

by any other means.


over research standards

and attention

to state

and federal regulations remain foci

of debate regarding fetal research.

Intrauterine fetal surgery,

which began

in 1981

and developed

through therapeutic research,

is a therapy

for anatomic lesions that

can be corrected surgically

and are incompatible

with life

if not treated.

Intrauterine fetal surgery involves opening the uterus during the second trimester

(before viability),

treating the fetal lesion,

and replacing the fetus

in the uterus.

The risks

to the fetus are substantial,

and the mother is committed

to cesarean births

for this

and subsequent pregnancies

because the upper,

active segment

of the uterus is incised during the surgery.

The parents must be informed

of the experimental nature

of the treatment,

the risks

of the surgery,

the commitment

to cesarean birth,

and alternatives

to the treatment.


with other aspects

of maternity care,

the pregnant woman’s autonomy must be respected.

The procedure does involve health risks

to the woman,

and she retains the right

to refuse any surgical procedure.

In 2001,

ACOG issued a news release calling fetal surgery “experimental.”

Speaking specifically

about fetal surgery

for open neural tube defects,

ACOG reported

that long-term neurologic outcomes have not yet been demonstrated

and the surgery exposes the mother

to the risks

of anesthesia,


preterm labor,

and uterine rupture

and also poses additional risk

to the fetus



Healthcare professionals are generally encouraged

to provide a clear summary

of the risks

and benefits

of a given approach and

to follow the principle

of nondirectiveness,


which only the client’s values are discussed during the decision-making process.


it is likely

that some “slippage”

in approach occurs,


can result

in a blurring

of the boundaries

between choice

and coercion.

This may be complicated

by the reality

that many women are influenced

by their views about

what it means

to be a “good” mother,

to behave responsibly.

As a result some women may feel

that they must opt

for a risky procedure

to avoid a sense

of blame

for failing

to do their “duty”



The dilemmas associated

with the consideration

of fetal surgery are challenging

and complex.

Healthcare providers must be careful

that their zeal

for new technology does not lead them

to focus unilaterally

on the fetus

at the expense

of the mother.

Reproductive Assistance

The number

and sophistication

of reproductive assistance techniques continue

to grow.

Infertile couples now have available a wide range

of reproductive options,

from therapeutic insemination to

in vitro fertilization

and beyond.

The ethical dimensions

of such techniques are discussed here.

The techniques themselves are identified

and described

in detail

in Chapter 12.

Therapeutic insemination


is accomplished

by depositing

into a woman sperm obtained

from her husband,


or other donor.

Some women

who are single are choosing TI

as a childbearing option.

No states prohibit therapeutic insemination using a husband’s sperm because

there is no question

of the child’s legitimacy.

Legal problems may occur

with TI using donor sperm,


Because the child is the biologic child

of the mother,

legal concerns center

on the donor.

A donor must sign a form waiving all parental rights.

The donor must also furnish accurate health information,

particularly regarding genetic traits

or diseases.

Donor sperm must be tested

for HIV.

Husbands often are requested

to sign a form

to agree

to the insemination and

to assume parental responsibility

for the child.

Some men legally adopt the child so

there is no question

of parental rights

and responsibilities.

Several states have enacted legislation regarding paternity

of the child conceived

by insemination

with donor sperm.

A variety

of procedures such

as testicular sperm aspiration


have been developed

to address severe male factor infertility.

Although these procedures have been quite promising,

they do raise questions

about the increased risk

of genetic defects related

to bypassing

of certain aspects

of the process

of natural selection.

In the United States

there are no established barriers

to the use

of these procedures.

Assisted reproductive technology


is the term used

to describe any fertility treatment


which both the egg

and sperm are handled.



which only the sperm are handled


therapeutic insemination)



which a woman takes medication

to stimulate egg production without subsequent egg retrieval are not included

in the definition

of ART.

In vitro fertilization

and embryo transfer


a therapy offered

to selected infertile couples,

is perhaps the best known ART technique.

Some effort has been made legislatively

to address consumer concerns

about ART.

In the United States,

the Federal Fertility Clinic Success Rate

and Certification Act


of 1992 addresses issues related

to laboratory quality

and the standardized reporting

of pregnancy success rates associated

with ART programs.

The act requires all clinics performing ART

in the United States

to report their success rates annually

to the Centers

for Disease Control

and Prevention



it does not contain provisions

to deal

with the unethical practices

that may occur,

nor does it address false reporting

of success rates.

To help ensure data accuracy,

a validation process,

which includes site visits

to a portion

of reporting clinics,

is completed.

The success rates

of the ART procedures vary significantly.


in 2002,

the highest success rate-50% live births-occurred

when donor eggs

and freshly fertilized embryos were used.


the largest percentage

of ART procedures occurred

among women

who used their own eggs.

Freshly fertilized embryos

from the woman’s own eggs resulted

in a live birth 34.8%

of the time,

although this varied

by maternal age,


from 43%

for women

under 35 years

to 7%

for women

over age 42.

The lowest success rate occurred

among women using their own eggs

and thawed embryos-24.8% resulted

in a live birth




& Jeng,


Of the births

that resulted

from ART

in 2002,

about 53% included more

than one fetus

(45.7% twins,

7.6% triplets

or greater)

(Wright et al.,


Multiple pregnancy occurs

because the use

of ovulation-inducing medications typically triggers the release

of multiple eggs,


when fertilized,

produce multiple embryos

that are

then implanted.

Multiple pregnancy increases the risk

of miscarriage,

preterm birth,

and neonatal morbidity

and mortality.

It also increases the mother’s risk

of cesarean birth and

of complications such

as hypertensive diseases

of pregnancy,

gestational diabetes,

and hemorrhage.

To help prevent a high-level multiple pregnancy,

the American Society

for Reproductive Medicine has issued guidelines

to limit the number

of embryos transferred.



supports the effort

to lower the risk

of multiple pregnancy

with ART.

The ethical dilemma

of what

to do

with the unused embryos remains a consideration.

when a multiple pregnancy does occur,

the physician may suggest

that the woman abort some

of the embryos-nonselective embryo reduction-to give the remaining embryos a better chance

for survival.

This procedure does raise ethical concerns

about the sacrifice

of some so

that the remainder

can survive



Surrogate childbearing is another approach

to addressing the issue

of infertility.

Surrogate childbearing occurs

when a woman agrees

to become pregnant

for another woman


for a couple

who are usually childless.


on the infertile woman’s

or couple’s needs,

the surrogate may be therapeutically inseminated

with the male partner’s sperm

or a donor’s sperm,

or she may

even receive a gamete transfer.

If fertilization occurs,

the woman carries the fetus

to term


then releases the infant

to the couple after birth.

These methods

of resolving infertility raise many ethical questions,

including the problem

of religious objections

to artificial conception,

the question



will assume financial

and moral responsibility

for a child born

with a congenital defect,

the issue

of candidate selection,

and the threat

of genetic engineering.

Other ethical questions include the following:

* What

should be done

with surplus fertilized oocytes?

* To whom do frozen embryos belong-parents together

or separately?

The hospital

or infertility clinic?

* Who is liable

if a woman

or her offspring contracts HIV disease

from donated sperm?

* Should children be told the method

of their conception?

Our son was born after artificial insemination.


my husband,

was sterile because

of radiation therapy,

so his cousin was the donor

for us.

I thought

that might be awkward

but the whole family was so excited


there was a way

to help us after Nick’s battle

with cancer

that it has been OK.

Every time we look

at Vincent Joseph

(he is named

for his grandfathers)

and see him smile,

we know

that we

would do it again

in an instant.

Embryonic Stem Cell Research

Human stem cells

can be found

in embryonic tissue and

in the primordial germ cells

of a fetus.

Research has demonstrated that

in tissue cultures these cells

can be made

to differentiate

into other types

of cells such

as blood,


or heart cells,

which might

then be used

to treat problems such

as diabetes,


and Alzheimer diseases,

spinal cord injury,

or metabolic disorders.

The availability

of specialized tissue


even organs grown

from stem cells might also decrease society’s dependence

on donated organs

for organ transplants.

in 2001,

President George W. Bush decided

to permit federal funding

of embryonic stem cell research,

but only

on the 64 existing cell lines identified

by the National Institutes

of Health


The president also announced the creation

of a President’s Council

on Bioethics,

which is

to oversee all federally funded embryonic stem cell research

and study the range

of ethical issues found

in the biomedical

and behavioral sciences.


that year the National Academy

of Sciences released a report

on the subject.

In the report the academy stated

that public funding

should be provided

for further stem cell research

and that,


new embryonic stem cell lines

will have

to be developed

(American Association

for the Advancement

of Science,



about embryonic stem cell research vary dramatically,

from the view

that any use

of human embryos

for research is wrong

to the view

that any form

of embryonic stem cell research is acceptable,

with a variety

of other positions

that fall somewhere


between these extremes.

Other questions also arise:

What sources

of embryonic tissue are acceptable

for research?

Is it ever ethical

to clone embryos solely

for stem cell research?


there justification

for using embryos remaining after fertility treatments?

The question


how an embryo

should be viewed-with status

in some way

as a person or

in some sense

as property


if property,

whose?)-is a key question

in the debate.

Ethicists recognize

that it is not necessary

to advocate full moral status

or personhood

for an embryo

to have significant moral qualms

about the instrumental use

of a human embryo

in the “interests”

of society.

The issue

of consent,

which links directly

to an embryo’s status,

also merits consideration.

The Bush policy,

like many proposed approaches,

requires parental consent



In truth,

the ethical questions

and dilemmas associated

with embryonic stem cell research are staggeringly complex

and require careful analysis

and thoughtful dialogue.

Cord Blood Banking

Cord blood,

which is taken

from a newborn’s umbilical cord

by the physician

or nurse-midwife assisting

with the birth,

may play a role

in combating leukemia,

certain other cancers,

metabolic disorders,

and other immune

and blood system disorders such

as sickle cell anemia,


and severe aplastic anemia.


umbilical cord blood cannot be used

to treat leukemia

or inborn errors

of metabolism

in the same child

who donated it

at birth



Cord blood,

like bone marrow,

contains regenerative stem cells,

which are able

to replace diseased cells

in the affected individual.

The value

of bone marrow transplants has long been recognized,

and a national registry

of potential bone marrow donors has been established.

The process

of collecting bone marrow is expensive

and uncomfortable,


and the National Marrow Donor Registry often has difficulty finding a matching bone marrow donor.

Cord blood has some advantages

over bone marrow:

* Collecting cord blood is less invasive

and involves no risk

to mother

or infant.

* Large-scale cord blood banking

would increase the availability

of stem cells

for minority groups,

who are seriously underrepresented

in bone marrow registries.

* Cord blood is less likely

than bone marrow

to trigger a potentially fatal rejection response.

* Cord blood works

with a less-than-perfect match.

* Cord blood is available

for use more rapidly

than bone marrow.

Cord blood banks

that process

and store cord blood have now been established

in the United States.

Cord blood banks may be public

or private.

Public banks receive cord blood units given

on a volunteer basis

and are designed

to support unrelated-donor transplant programs.

Private banks are for-profit entities designed primarily

for families

who plan

to use the cord blood

for the infant

who provided the blood

(autologous donation)


for another family member

who might need transplantation therapy

in the future because

of a genetic blood condition,


bone marrow failure,

or inborn error

of metabolism,

for example.

In 2005 the Institute

of Medicine


completed a study

for the Health Resources

and Services Administration



on identifying the best way

to organize public cord blood banking

and distribution

to individuals

in need.

The IOM study recommended

that HRSA establish contracts

with eligible public banks

to procure approximately 150,000 new units

of cord blood

from ethnically diverse unrelated donors

over the next 5 years

and list them

on a computerized Web-based system

to allow searching

of all unrelated cord blood units



& Sugarman,


Legislation authorizing funding passed

in 2005.

Ethical issues associated

with cord blood banking include the following

(Smith & Thomson,


* Who owns the blood?

The donor?

The parents?

Private blood banks?


* How

will informed consent be obtained and

by whom?

* How

will confidentiality be ensured?

Family members need

to understand that,

if they choose

to donate,

the mother

will be asked

to provide a blood sample

and a detailed history

about her health

and infectious disease status.

* How

will obligations

to notify the family

and donor be addressed

if testing

of the blood reveals infectious diseases

or genetic disorders?


there be any ongoing assessment

of donors so that

if health problems develop,


can be notified?

* How

can the harvested blood be distributed fairly,


that it is available

to individuals

from all races,

ethnic groups,

and income levels?


for Nursing Practice

The complex ethical issues facing maternal-newborn nurses have many social,



and professional ramifications.


like all healthcare professionals,


to learn

to anticipate ethical dilemmas,

clarify their own positions

and values related

to the issues,

understand the legal implications

of the issues,

and develop appropriate strategies

for ethical decision making.

To accomplish these tasks,

they may read

about bioethical issues,


in discussion groups,

or attend courses

and workshops

on ethical topics pertinent

to their areas

of practice.

Most nurses develop solid skills

in logical thinking

and critical analysis.

These skills,


with theoretical knowledge

about ethical decision making,

can serve nurses well

in dealing

with the many ethical dilemmas found

in health care.



Increasingly nurses are recognizing the value

and usefulness

of statistics.

Health-related statistics provide an objective basis

for projecting client needs,

planning use

of resources,

and determining the effectiveness

of treatment.

there are two major types

of statistics:


and inferential.

Descriptive statistics describe

or summarize a set

of data.

They report the facts-what is-in a concise

and easily retrievable way.

How the data are compiled

and presented is determined

by the question being asked.

An example

of a descriptive statistic is the birth rate

in the United States.

Although no conclusion may be drawn

from these statistics about

why some phenomenon has occurred,


can identify certain trends

and high-risk “target groups”

and generate possible research questions.

Inferential statistics allow the investigator

to draw conclusions

or inferences about

what is happening

between two

or more variables

in a population and

to suggest

or refute causal relationships

between them.

For example,

descriptive statistics reveal

that the infant mortality rate

in the United States has declined

over the past decade.



that trend has occurred cannot be answered

by simply looking

at these data,


More data

and inferential statistics using smaller samples

of the population

of pregnant women are needed

to determine whether this finding is because

of earlier prenatal care,

improved maternal nutrition,


of electronic fetal monitoring during labor,

and/or any number

of factors potentially associated

with maternal-fetal survival.

Descriptive statistics are the starting point

for the formation

of research questions.

Inferential statistics answer specific questions

and generate theories

to explain relationships

between variables.

Theory applied

in nursing practice

can help change the specific variables

that may cause

or contribute

to certain health problems.

This section discusses descriptive statistics

that are particularly important

to maternal-newborn health care.


that may be drawn

from these descriptive statistics are addressed

as possible research questions

that may help identify relevant variables.

Birth Rate

Birth rate refers

to the number

of live births per 1000 people.

In 2004,

the US birth rate was 14 per 1000,

a slight decrease

from the 2003 rate

of 14.1.

Table 1-1 provides valuable information

about births

in the United States

in 2003

and 2004.

In 2004

there were 4.1 million births.

The number

of births

to white


women decreased,

whereas the number

of births

to black women remained essentially unchanged.


to Hispanic,

Native American,

and Asian/Pacific Islander women increased.

Teenage birth rates decreased

for all race

and ethnic groups,

whereas birth rates

for women ages 30

to 44 increased




& Sutton,




by AGE,






and 2004

1Includes origin not stated.

2The total number includes births

to women

of all ages,

10-54 years.

The rate shown

for all ages is the fertility rate,

which is defined

as the total number

of births,


of age

of mother,

per 1000 women aged 15-44 years.

3The number

of births shown is the total

for women aged 45-54 years.

The birth rate is computed

by relating the number

of births

to women aged 45-54 years

to women aged 45-49 years,

because most

of the births

in this group are

to women aged 45-49.

4Includes births

to Aleuts

and Eskimos.


for persons

of Hispanic origin are included

in the data

for each race group according

to the mother’s reported race,

see “Technical Notes.”

6Includes all persons

of Hispanic origin

of any race;

see “Technical Notes.”



and Hispanic origin are reported separately

on birth certificates.


of Hispanic origin may be

of any race.

Race categories are consistent

with the 1977 Office

of Management

and Budget



Fifteen states reported multiple-race data

for 2004.

The multiple-race data

for these states were bridged

to the single race categories

of the 1977 OMB standards

for comparability

with other states;

see “Technical Notes”

and references 1

and 2.



B. E.,


S. J.,


J. A.,

& Sutton, 

P. D. (2005,

October 28).

Preliminary births

for 2004.

Health E-Stats.



National Center

for Health Statistics.






from The World Fact Book 2006.



The Central Intelligence Agency.


by unmarrried women continued

to increase

in 2004,

reaching record highs-almost 1.5 million births-an increase

of 4%.

In fact,


of all births were

to unmarried women.


these increases occurred

in all ages,


and Hispanic-origin subgroups




& Sutton,


The cesarean birth rate reached record levels,


by 6%

to 29%

of all births

in 2004.

Concurrently the rate

of vaginal birth after cesarean


dropped 13%

from 10.6%

in 2003

to 9.2%

in 2004

(National Center

for Health Statistics



Birth rates also vary dramatically

from country

to country.

Table 1-2 identifies the birth rates

for selected countries.

* Is

there an association

between birth rates

and changing societal values?

* Do the differences

in birth rates

between various age groups reflect education?

Changed attitudes

toward motherhood?

* Do the differences

in birth rates

among various countries reflect cultural differences?

Do they represent availability

of contraceptive information?


there other factors

at work?

Infant Mortality

The infant mortality rate is the number

of deaths

of infants

under 1 year

of age per 1000 live births

in a given population.

In 2003 the US infant mortality rate was 6.85,

a decrease

over 2002.

The year 2002 was marked

by the first increase

in infant mortality

in more

than 40 years

(Table 1-3).


the infant mortality rate varied widely

by race

of the mother,

from 5.17

for infants

of white mothers

to 14.01

for infants

of black mothers




& Kung,


Neonatal mortality is the number

of deaths

of infants less

than 28 days

of age per 1000 live births.

Perinatal mortality includes both neonatal deaths

and fetal deaths per 1000 live births.

(Fetal death is death

in utero

at 20 weeks’

or more gestation.)

Figure 1-6

( shows the leading causes

of deaths

of infants

in the United States

from 1940

to 2003.





UNITED STATES 1982-2002.


1Partially edited data processed

through January 2004.


Health E-Stats.

Supplemental Analysis

of Recent Trends

in Infant Mortality.


The US infant mortality rate has continued

to be

of concern

because the United States has fallen

to 22nd place

among industrialized nations

in infant mortality rankings.

Healthcare professionals,

policy makers,

and the public have continued

to stress the need

in the United States

for better prenatal care,


of health services,

and the provision

of comprehensive maternal-child services.

Table 1-2 identifies infant mortality rates

for selected countries.

As the data indicate,

the range is dramatic

among the countries listed.



about birth rates

and mortality rates is limited

for some countries because

of a lack

of organized reporting mechanisms.

The information prompts questions

about access

to health care during pregnancy

and following birth,


of living,


sociocultural factors,

and more.

Additional factors affecting the infant mortality rate may be identified

by considering the following research questions:

* Does infant mortality correlate

with a specific maternal age?

* What are the leading causes

of infant mortality

in each country?

* Is

there a difference

in mortality rates

among racial groups?

If so,

is it associated

with the availability

of prenatal care?

With educational level

of the mother

or father?

Maternal Mortality

The maternal mortality rate is the number

of deaths

from any cause related


or aggravated

by pregnancy

or its management during the pregnancy cycle

(including the 42-day postpartal period)

per 100,000 live births.

It does not include accidental

or unrelated causes.

Between 2002

and 2003 maternal deaths increased

by 138 deaths,


in a maternal mortality rate

of 12 per 100,000 live births.

This increase

in part reflects the fact

that a growing number

of states are using a separate item

on the death certificate

to help identify pregnancy-related deaths

(Hoyert et al.,


Table 1-4 identifies the number

of maternal deaths

and maternal mortality rates

for 2003.

In general,

maternal mortality rates are significantly lower

than they were 25 years ago.

Factors influencing the decrease

in maternal mortality include the increased use

of hospitals

and specialized healthcare personnel

by antepartal,


and postpartal maternity clients;

the establishment

of care centers

for high-risk mothers

and infants;

the prevention

and control

of infection

with antibiotics

and improved techniques;

the availability

of blood

and blood products

for transfusions;

and the lowered rates

of anesthesia-related deaths.

Additional factors

to consider may be identified

by asking the following research questions:

* Is

there a correlation

between maternal mortality

and age?

* Is

there a correlation

with availability

of health care?

Economic status?


for Nursing Practice


can use statistics

in a number

of ways.

For example,

statistical data may be used to:

* Determine populations

at risk

* Assess the relationship

between specific factors

* Help establish databases

for specific client populations

* Determine the levels

of care needed

by particular client populations

* Evaluate the success

of specific nursing interventions

* Determine priorities

in caseloads

* Estimate staffing

and equipment needs

of hospital units

and clinics

Table 1-4 NUMBER




by RACE:



*Figure does not meet standards

of reliability followed

by National Center

for Health Statistics.


Hoyert et al.



Final Data

for 2003.

National Vital Statistics Report,



Statistical information is available

through many sources,

including professional literature;


and city health departments;

vital statistics sections

of private,



and federal agencies;

special programs

or agencies


and similar agencies);

and demographic profiles

of specific geographic areas.


of these sources are accessible via the Internet.


who use this information

will be better prepared

to promote the health needs

of maternal-newborn clients

and their families.



Evidence-based practice-that is,

nursing care


which all interventions are supported

by current,

valid research evidence-is emerging

as a force

in health care.

It provides a useful approach

to problem solving/decision making and

to self-directed,


lifelong learning.

Evidence-based practice builds

on the actions necessary

to transform research findings

into clinical practice

by also considering other forms

of evidence that

can be useful

in making clinical practice decisions.

These other forms

of evidence may include,

for example,

statistical data,

quality improvement measurements,

risk management measures,

and information

from support services such

as infection control.

as clinicians,

nurses need

to meet three basic competencies related

to evidence-based practice:

1. To recognize

which clinical practices are supported

by sound evidence,

which practices have conflicting findings as

to their effect

on client outcomes,


which practices have no evidence

to support their use

2. To use data

in their clinical work

to evaluate outcomes

of care

3. To appraise

and integrate scientific bases

into practice


some agencies

and clinical units

where nurses practice still operate

in the old style,

which often generates conflict

for nurses

who recognize the need

for more responsible clinical practice.

In truth,

market pressures are forcing nurses

and other healthcare providers

to evaluate routines

to improve efficiencies

and provide better outcomes

for clients.

Nurses need

to know

what data are being tracked

where they work and

how care practices

and outcomes are improved

as a result

of quality improvement initiatives.


there is more

to evidence-based practice

than simply knowing

what is being tracked and

how the results are being used.


effective nurses learn

to question the very basis

of their clinical work.

Throughout this text we have provided snapshots

of evidence-based practice related

to childbearing women,


and families such

as the one

on page 80.

We believe

that these snapshots

will help you understand the concept more clearly.

We also expect

that these examples may challenge you

to question the usefulness

of some

of the routine care you observe

in clinical practice.

That is the impact

of evidence-based practice-it moves clinicians beyond practices

of habit

and opinion

to practices based

on reliable,


current science.

Nursing Research

Research is vital

to expanding the science

of nursing,

fostering evidence-based practice,

and improving client care.

Research also plays an important role

in advancing the profession

of nursing.

For example,

nursing research

can help determine the psychosocial

and physical risks

and benefits

of both nursing

and medical interventions.

The gap

between research

and practice is being narrowed

by the publication

of research findings

in popular nursing journals,

the establishment

of departments

of nursing research

in hospitals,

and collaborative research efforts

by nurse researchers

and clinical practitioners.

Interdisciplinary research

between nurses

and other healthcare professionals is also becoming more common.

This ever-increasing recognition

of the value

of nursing research is important

because well-done research supports the goals

of evidence-based practice.

Most chapters

of this text,


include Research

in Practice boxes such

as the one shown

on p. 37.

Clinical Pathways

and Nursing Care Plans

One result

of nursing research

into the nursing process has been the creation

of clinical pathways.

Clinical pathways specify essential nursing activities

and provide basic guidelines

about expected outcomes

at specified time intervals.

These guidelines are research based

and enable the nurse

to determine whether a client’s responses meet expected norms

at any given time.

In the text,

we have provided sample clinical pathways

for a woman experiencing a normal vaginal birth

and a cesarean birth.

We have also provided sample clinical pathways

for the normal newborn


for a woman

in the postpartal period.

Nursing care plans,

which use the nursing process

as an organizing framework,

are also invaluable

in planning

and organizing care.

Care plans are especially valuable

for nursing students

and novice nurses.

To help organize care,

this text also provides several examples

of nursing care plans such

as those found

in Chapter 19.

Evidence-Based Practice:

An Example

in using evidence-based practice,

nurses draw

on a variety

of tools such

as statistical data,

nursing research

and other research,


of care,


and critical analysis skills.

These tools

can exist separately,


in practice they overlap

and build upon each other.

An example

of just one possible situation is presented

in the following case study.

Two birthing unit nurses express concerns

to each other

about the seemingly high number

of adolescents

who have been giving birth

in their unit.

At the next staff meeting,

they voice their concerns

and raise questions

about whether the number

of teenage mothers seen

in their unit is higher

than normal.

After the discussion,

the nurses decide they need

to formulate a plan

to gather more information.

Each nurse volunteers

to pursue a particular aspect

of the plan

of action.

Their plan includes contacting the local public health department

for local

and national statistics

on this age group;


at the availability

of health care

for adolescents

in their community;

investigating the particular health problems

of pregnant teenagers

and risks

to their infants;

checking the availability

of prenatal education groups

for adolescents;

finding out whether their community has school health programs


what the program content is;


at national statistics identifying

when adolescents seek prenatal care;


with local certified nurse-midwives,


and prenatal clinic personnel

to see

if the national statistics apply

to their community;

collecting information

about current legislative issues affecting adolescent health care;

seeking further information

about the needs

of adolescents during pregnancy

and birth

by doing a library search;

and looking

for continuing education programs dealing

with the pregnant adolescent client.

at subsequent staff meetings,

nurses share information

and investigate other areas

as the need is identified.

How they evaluate the data

and apply them

will depend

on the requirements

of their maternal-newborn unit

and the unique needs

of their community.

Possible outcomes may include developing a research study,


in local adolescent clinics,


and teaching prenatal classes

for adolescents,


to teach

in community school health programs,

organizing a continuing education program

on the adolescent mother

for community hospitals,

and forming a network within their professional nursing organization

to stay informed

about legislative issues pertaining

to adolescents.

as the example illustrates,

the application

of tools

of evidence-based practice assists the nurse

in analyzing data

and planning a course

of action.



* Many nurses working

with childbearing families are expert practitioners

who are able

to serve

as role models

for nurses

who have not yet attained the same level

of competence.

* Contemporary childbirth is family centered,

offers choices

about birth,

and recognizes the needs

of siblings

and other family members.

* The self-care movement,

which emerged

in the late 1960s,

emphasizes personal health goals,

a holistic approach,

and preventive care.

* The US healthcare system is facing a variety

of challenges including the high cost

of health care

and the need

for cost containment

while retaining quality;

the large numbers

of uninsured

and underinsured people;

high infant mortality rates

as compared

with other industrialized nations;

and a high incidence

of poverty,


among children

and women-headed households.

* The nurse

who provides culturally competent care recognizes the importance

of the childbearing family’s value system,


that differences occur

among people,

and seeks

to respect

and respond

to ethnic diversity

in a way

that leads

to mutually desirable outcomes.

* A nurse must practice within the scope

of practice

or be open

to the accusation

of practicing medicine without a license.

The standard

of care against

which individual nursing practice is compared is that

of a reasonably prudent nurse.

* Nursing standards provide information

and guidelines

for nurses

in their own practice,

in developing policies

and protocols

in healthcare settings,


in directing the development

of quality nursing care.

* Informed consent-based

on knowledge

of a procedure

and its benefits,


and alternatives-must be secured

before providing treatment.

* State constitutions,


and common law protect the right

to privacy.

* Maternal-fetal conflict may arise

when the fetus is viewed

as a person

of equal rights

to those

of the mother’s

and external agents attempt

to force the mother

to accept a therapy she wishes

to refuse,

or similarly attempt

to restrict a mother’s actions

to support the well-being

of the fetus.

* Abortion

can be performed

until the age

of viability.

Caregivers have the right

to refuse

to perform an abortion

or assist

with the procedure.

* A variety

of procedures are available

to help infertile couples achieve a pregnancy.



of these procedures provoke serious ethical dilemmas.

* Embryonic stem cell research using human stem cells obtained

from a human embryo is marked

by controversy.

On the one hand,

it raises the possibility

of treatment

for a variety

of major diseases such

as diabetes,

Parkinson disease,

and Alzheimer disease.

On the other hand,

ethicists question the ethical implications

of using embryonic tissue-especially tissue obtained specifically

for stem cell research.

* Cord blood banking provides the opportunity

to make stem cells available

to treat a variety

of cancers

and blood system disorders.

Its growing popularity has revealed several ethical issues,

such as:

Who owns the blood?


will informed consent be obtained and

by whom?


will confidentiality be ensured?


can the harvested blood be distributed fairly,


that it is available

to individuals

from all races,

ethnic groups,

and income levels?

And so forth.

* Descriptive statistics describe

or summarize a set

of data.

Inferential statistics allow the investigator

to draw conclusions about

what is happening

between two

or more variables

in a population.

* Evidence-based practice-that is,

nursing care


which all interventions are supported

by current,

valid research evidence-is emerging

as a positive force

in health care.

* Nursing research plays a vital role

in adding

to the nursing knowledge base,

expanding clinical practice,

and expanding nursing theory.



NCLEX review questions,

case studies,

and other interactive resources

for this chapter

can be found

on the Web Site

at http://www.prenhall.com/davidson.


on “Chapter 1”

to select the activities

for this chapter.

for tutorials including animations

and videos,

more NCLEX review questions,

and an audio glossary,

access the accompanying Prentice Hall Nursing MediaLink DVD-ROM

in this book.

prentice hall nursing medialink dvd-rom

Audio Glossary

NCLEX Review

companion website

Additional NCLEX Review

Case Study:

Cord Blood Banking

Care Plan Activity:


for Second Trimester Abortion



of Practice;


of Care

Critical Thinking



culturally competent care

View the Critical Thinking

in Action video

in Chapter 1

of the DVD-ROM.

Then answer the questions

that follow.

You are working

as a prenatal nurse

in a local clinic.

Before entering a client’s room,

you review the chart

for pertinent information such

as cultural background,

significant family members,


of gestation,

test results,

birth plan,

and education

for health promotion.

You greet each client

and family member

by name

and ask

how they are coping

with the pregnancy.


on the trimester

of the pregnancy,

you review the discomforts

or concerns

of the mother/family


what they may expect.

You examine the mother,

including fundal height,

fetal heart rate

and fetal position

if appropriate,

maternal blood pressure,

weight gain,

and urine analysis.

With each client,

you discuss the community resources available such

as prenatal classes,

lactation consultants,

and prenatal exercise/yoga classes.

Based upon the information you obtain,

you might refer the mother

to social services

or the WIC program

as appropriate.

At the end

of the clinic session,

you review the clients

with the collaborating physician.

1. How

would you define the terms family

and family-centered care?

2. Describe

how the nursing process provides the framework

for the delivery

of direct nursing care.

3. How

would you describe the concept

of community-based care?

4. How

would you describe culturally competent care?