UNIT 1
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
CHAPTER 1
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!
KEY TERMS
Assisted reproductive technology
(ART)
15
Birth rate 17
Certified nurse-midwife
(CNM)
8
Certified registered nurse
(RNC)
8
Client 5
Clinical nurse specialist
(CNS)
8
Evidence-based practice 20
Infant mortality rate 18
Informed consent 11
Intrauterine fetal surgery 14
Maternal mortality rate 19
Nurse practitioner
(NP)
8
Professional nurse 8
Therapeutic insemination
(TI)
14
OBJECTIVES
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,
times
in
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,
care
about people,
and use their expertise
to help people help themselves.
I
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
of
what I do,
and I feel the need
to seize every chance
to influence those
who
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,
doing
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,
coaching
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,
“Oh,
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
of
what we do!
All nurses
who provide care
and support
to childbearing women
and their families
can make a difference.
But
how does this happen?
How do nurses develop expertise
and become skilled,
caring practitioners?
in her classic work,
Benner
(1984)
suggested that
as nurses develop their skills
in making clinical judgments
and intervening appropriately,
they progress
through five levels
of competence.
Beginning
as a novice,
the nurse progresses
to advanced beginner
and then
to competent,
proficient,
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
on
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
of
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,”
especially
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;
antepartal
and postpartal nurses become adept
at assessing
and teaching.
Similarly,
nurses
who are cross-trained
as labor,
delivery,
recovery,
and postpartum
(LDRP)
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,
who
can demonstrate only marginally acceptable performance
(Benner,
1984)
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.
Nurses
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,
“Oh,
yes,
please,”
and she left.
I’ve never forgotten
how
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,
intuitive,
knowledgeable,
critical thinkers.
They are technically skilled,
empowered professionals
who
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.
CONTEMPORARY CHILDBIRTH
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
and
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.
Families
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,
sister,
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
(hospital,
free-standing birthing center,
or home birth);
the primary caregiver
(physician,
certified nurse-midwife,
or certified midwife);
and birth-related experiences
(methods
of childbirth preparation,
use
of analgesia
and anesthesia,
and position
for labor
and birth,
for example).
as recently
as the early 1990s,
women
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.
However,
because early discharge severely limits the time available
for client teaching,
women
with little knowledge,
experience,
or support were
at greater risk
of being inadequately prepared
to care
for themselves
and their newborn infants.
Fortunately,
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.
However,
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,
families
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.
Interest
in complementary
and alternative medicine
(CAM)
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
(CNM),
a registered nurse
who is also prepared
as a midwife.
Accreditation
of the CNM is offered
through the American College
of Nurse-Midwives
(ACNM).
The preparation
and role
of the CNM is described
on page 8.
Some women choose
to receive care
from a direct-entry certified midwife
or
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},
2006]).
Midwives
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
(CM).
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
(ACNM,
2005).
The North American Registry
of Midwives
(NARM)
is also a certification agency.
Midwives certified
through NARM may become midwives
through a formal educational program
at a college,
university,
or midwifery school,
or
through apprenticeship
or self-study.
They are eligible
to use the credential certified professional midwife
(CPM).
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,
delay
in obtaining emergency assistance might result.
Some CNMs do attend home births;
however,
the majority
of home births are attended
by CMs,
CPMs,
or lay midwives.
THE SELF-CARE MOVEMENT
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.
More
and more people have begun
to exercise,
control their diet,
monitor their psychologic
and physiologic status,
and
in some cases
even do their own diagnostic tests.
They thus assume many primary care functions.
Furthermore,
today’s healthcare consumers are requiring greater information
and accountability
from their healthcare providers.
These consumers recognize
that knowledge,
indeed,
is power.
Practicing self-care-assuming responsibility
for one’s own health-often requires assertiveness
and taking an active role
in seeking necessary information.
Nurses
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.
Obviously,
self-care is not always realistic
or appropriate,
especially
in acute emergencies,
but
in many situations it is appropriate.
With this
in mind,
throughout this book we have attempted
to suggest ways
in
which nurses might offer health education
that
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.
Because
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,
rather
than a passive,
role.
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.
Furthermore,
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.
THE HEALTHCARE ENVIRONMENT
Healthcare issues are
at the top
of policy
and legislative agendas.
Cost,
access,
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
(GDP).
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
(Smith,
Cowan,
Heffler,
& Catlin,
2006).
Despite this increase
in spending,
however,
not all pregnant women
and children
in the United States have access
to health care.
In 2005,
16%
of people
under age 65
(41 million)
were without health insurance
(Figure 1-2
().
People
with incomes below
or near the poverty level were significantly more likely
to be uninsured,
as were people
of Hispanic origin
(Cohen & Martinez,
2006).
For people living
in poverty,
Medicaid is the most prevalent form
of insurance.
Together Medicaid,
the State Children’s Health Insurance Program
(SCHIP)
(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
(
(Centers
for Medicare
and Medicaid Services
[CMS],
2006).
for women
who become pregnant,
early prenatal care is one
of the most important approaches available
to reduce adverse pregnancy outcomes.
In 2003,
84.1%
of pregnant women
in the United States began prenatal care
in the first trimester.
However,
these percentages vary significantly
among groups,
with black,
Hispanic,
and Native American women less likely
to receive early
and adequate prenatal care
than white
and Asian women
(National Center
for Health Statistics
[NCHS],
2005a).
The United States spends more per capita
than any other country
in the world
on health care;
nevertheless,
compared
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,
such
as AIDS
and tuberculosis,
and
in chronic illnesses,
such
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.
However,
little actual change occurred
in the percentage
of those uninsured because
of the increase
in the percentage
of people served
by Medicaid
(NCHS,
2005a).
Many
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
if
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
on
which all other secondary
and tertiary services are built.
Today
in the United States the opposite is still the case.
The system emphasizes high-technology care rather
than prevention.
However,
morbidity
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%.
Similarly,
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,
increasing
from 29%
to 69.5%
(NCHS,
2005a).
The new Health Insurance Portability
and Accountability Act
(HIPAA)
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,
physicians,
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,
prevention,
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.
However,
this opportunity
for responding
to
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,
especially
in community-based nursing practice
and advanced practice roles such
as nurse practitioners
(NPs)
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,
so
will the need for,
and utilization of,
nurses
in advanced practice roles.
CULTURALLY COMPETENT CARE
The US population has a varied mix
of cultural groups,
with ever-increasing diversity.
More
than one third
of all children less
than 20 years
of age are
from families
of minority populations.
Culture develops
from socially learned beliefs,
lifestyles,
values,
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,
respect,
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
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,
especially
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.
Because
of the importance
of culturally competent care,
this topic is discussed
in more depth
in Chapter 2
and throughout the book
as well.
PROFESSIONAL OPTIONS
in MATERNAL-NEWBORN NURSING PRACTICE
as a man,
I
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,
too.
I
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,
too.
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,
period!
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,
and
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
(NCLEX-RN)
and is currently licensed
as a registered nurse
(RN).
Professional nurses are typically educated
as generalists.
* A certified registered nurse
(RNC)
has shown expertise
in a particular field
of nursing such
as labor
and delivery
by taking a national certification examination.
* A nurse practitioner
(NP)
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
(CNS)
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
(CNM)
is educated
in the two disciplines
of nursing
and midwifery
and is certified
by the American College
of Nurse-Midwives
(ACNM).
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
(ACOG)
and the ACNM issued a joint statement describing the independent,
collaborative,
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,
trust
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
(ACOG,
2001).
The term advanced practice nurse is used
to describe nurses who,
by education
and practice,
function
in an expanded nursing role.
The term,
often used
in a legal sense
in state nurse practice acts,
most frequently applies
to NPs,
CNSs,
CRNAs
(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,
such
as lactation consultants,
social workers,
or CNSs
(Figure 1-5
().
Successful teams have certain characteristics
(Simpson & Knox,
2001):
* They have established consensus
about their mission
and vision,
their goals,
and their objectives
and strategies.
* They recognize,
respect,
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.”
Rather,
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,
workplaces,
homes,
churches,
clinics,
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
(adolescents,
disabled women,
ethnic
or racial minorities).
Community-based care remains an essential element
of health care
for uninsured
and underinsured individuals
as well
as
for those individuals
who benefit
from programs such
as Medicare
or state-sponsored health-related programs.
Some
of these programs,
such
as those offered
through public health departments,
are broad based;
others,
such
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,
comprehensive,
coordinated health care,
health education,
and social services.
This seamless system requires coordination
as clients move
from primary care services
to acute care facilities
and
then back
into the community.
The shortened length
of hospital stays further mandates the need
for coordination
of services.
Nurses
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,
offices,
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.
However,
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,
assistance,
and teaching.
Home care
can help fill this gap.
Conversely,
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,
nurses
can use their skills
in assessment,
therapeutics,
communication,
teaching,
problem solving,
and organization
to meet the needs
of childbearing families.
They also play a major role
in coordinating services
from other providers,
such
as physical therapists
or lactation consultants.
Postpartum
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
on
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.
LEGAL
and ETHICAL CONSIDERATIONS
Professional nursing practice requires full understanding
of practice standards,
institutional
or agency policies,
and local,
state,
and federal laws.
Professional practice also requires an understanding
of the ethical implications
of those standards,
policies,
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.
Scope
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,
diagnostic
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,
perinatal,
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,
failing
to assess properly,
failing
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
(pain
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.
Standards
of Nursing Care
Standards
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
on
what a reasonably prudent nurse
with similar education
and experience
would do
in similar circumstances.
SOURCES
of CARE STANDARDS Written standards
of care are provided
by a number
of different sources.
The American Nurses Association
(ANA)
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,
such
as the Association
of Women’s Health,
Obstetric,
and Neonatal Nurses
(AWHONN),
the Association
of Operating Room Nurses
(AORN),
and the National Association
of Neonatal Nurses
(NANN),
have developed standards
of specialty practice.
Agency policies,
procedures,
and protocols also provide appropriate guidelines
for care standards.
The Joint Commission
on Accreditation
of Healthcare Organizations
(JCAHO),
a private,
nongovernmental agency
that audits the operation
of hospitals
and healthcare facilities,
has also contributed
to the development
of nursing standards.
Agency policies,
procedures,
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
that
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,
and
to evaluate the effectiveness
of care.
Some standards carry the force
of law;
others,
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.)
However,
any nurse
who practices within the guidelines established
by agency,
local,
or national standards is assured
that clients are provided
with competent nursing care,
which,
in turn,
diminishes the potential
for litigation.
ETHICAL COMPONENTS
of CARE STANDARDS Standards
of care are based
on a legal model rather than
on ethics.
However,
they incorporate important ethical components
that extend the narrow legal interpretation
of the term standard.
Although
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,
agencies,
or hospitals.
Ethics,
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,
benefits,
other relationships,
concerns,
and the needs
and abilities
of persons affected
by
and affecting decisions.
Law
and ethics are interrelated;
they share a similar decision process
and standards.
Both disciplines incorporate fact-finding,
conflict negotiation,
prioritization
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
in
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,
unwise
and inappropriate
from a medical perspective,
yet fully justifiable ethically.
Similarly,
legally sanctioned maintenance
of life support
for a severely damaged newborn
with little hope
for meaningful existence may remain a medically viable alternative,
but
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
Law
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,
privacy,
and confidentiality.
CLIENT/PATIENT SAFETY The Joint Commission
on the Accreditation
of Healthcare Organizations
(JCAHO)
(2006)
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
to
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,
medical,
or surgical intervention.
To touch a person without consent
(except
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.
Finally,
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.
Anxiety,
fear,
pain,
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,
experience,
and capacity
for judgment
in life’s difficult decisions.
Although the age
of majority is 18 years
in most states,
variations
in certain states require
that nurses be aware
of the law
in the state
where they practice.
Children
under 18
or 21 years
of age,
depending
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,
2000)
Mature minors
(14-
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,
however,
a pregnant teenager is considered an emancipated minor
and may therefore give consent
for herself
as well.
Additionally,
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.
Refusal
of a treatment,
medication,
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.
Afterward,
the nurse documents the teaching
and the learning outcomes
in the person’s record.
The importance
of clear,
concise,
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.
RIGHT
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
(NLN),
and JCAHO have adopted professional standards protecting clients’ privacy.
Healthcare agencies
should also have written policies dealing
with client privacy.
HIPAA,
discussed previously,
also has a provision
to guarantee the security
and privacy
of health information.
Laws,
standards,
and policies
about privacy specify
that information
about clients’ treatment,
condition,
and prognosis
can be shared only
by the health professionals responsible
for their care.
Authorization
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,
age,
occupation,
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,
client
and attorney,
husband
and wife,
and clergy
and those
who seek their counsel.
In some states,
laws
of privilege also protect nurses.
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,
hospital,
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.
Computerization
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.
However,
with an advance directive
in place,
a childbearing woman
can be certain that,
even
if she becomes incompetent,
she
can retain her autonomy
about healthcare decisions.
Nurses often discuss these issues
with clients
and their families
and
can help them explore their beliefs
and values
about treatment options
and dying.
CLINICAL TIP
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,
social,
or physical harm
for some clients.
Ethical Decision Making
Healthcare
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,
duties,
theories,
principles,
values,
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,
and
who
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,
prognosis,
treatment options,
available health care,
and psychosocial,
spiritual,
financial,
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,
changes
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,
determine
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,
however,
increase the likelihood
of addressing multiple needs
in complex care situations
in an ethically appropriate
and legal manner.
SPECIAL ETHICAL SITUATIONS
in MATERNITY CARE
Maternity care is fraught
with unique circumstances
in
which an ethical dilemma may arise.
These include situations
of maternal-fetal conflict,
issues related
to termination
of pregnancy,
embryonic
and fetal research,
reproductive assistance,
and cord blood banking.
Additionally,
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.
Mother
and fetus were viewed
as one complex client-the pregnant woman-of
which the fetus was an essential part.
However,
advances
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,
tends
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,
however,
women have refused interventions
on behalf
of the fetus,
and forced interventions have occurred.
These include forced cesarean birth,
coercion
of mothers
who practice high-risk behaviors such
as substance abuse
to enter treatment,
and,
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
(Hornstra,
1999).
These forced interventions raise two thorny questions:
(1)
What practices
should be monitored?
and
(2)
Who
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
or
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
(ACOG,
2005a).
The American College
of Obstetricians
and Gynecologists
(ACOG)
(2004)
and the American Academy
of Pediatrics
(AAP)
Committee
on Bioethics
(1999)
both affirm the fundamental right
of pregnant women
to make informed,
uncoerced decisions
about medical interventions.
Moreover,
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
as
if they were moral failings.(
4. Coercive
and punitive policies are potentially counterproductive
in
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”
(ACOG,
2005a,
pp. 6-9).
ACOG
and AAP recognize
that cases
of maternal-fetal conflict involve two clients,
both
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.
Abortion
since the 1973 Supreme Court decision
in Roe v.
Wade,
abortion has been legal
in the United States.
It
can be performed
until the period
of viability,
after
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.
Nevertheless,
few issues spark the intensity
of response seen
when the issue
of abortion is raised.
at present,
decisions
about abortion are made
by a woman
and her physician.
Nurses
(and other caregivers)
have the right
to refuse
to assist
with the procedure
if abortion is contrary
to their moral
and ethical beliefs.
However,
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,
nurses
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,
regardless
of the nurse’s beliefs.
Fetal Research
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,
and
that the information be unobtainable
by any other means.
Control
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.
as
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,
hemorrhage,
preterm labor,
and uterine rupture
and also poses additional risk
to the fetus
(ACOG,
2001).
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,
in
which only the client’s values are discussed during the decision-making process.
However,
it is likely
that some “slippage”
in approach occurs,
which
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”
(Williams,
2006).
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
(TI)
is accomplished
by depositing
into a woman sperm obtained
from her husband,
partner,
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,
however.
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
(TESA)
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
(ART)
is the term used
to describe any fertility treatment
in
which both the egg
and sperm are handled.
Treatments
in
which only the sperm are handled
(e.g.,
therapeutic insemination)
or
in
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
(IVF-ET),
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
(FCSRCA)
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
(CDC).
However,
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.
Specifically,
in 2002,
the highest success rate-50% live births-occurred
when donor eggs
and freshly fertilized embryos were used.
However,
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,
ranging
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
(Wright,
Schieve,
Reynolds,
& Jeng,
2005).
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.,
2005).
Multiple pregnancy occurs
because the use
of ovulation-inducing medications typically triggers the release
of multiple eggs,
which,
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.
ACOG
(2005b)
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
(ACOG,
2002).
Surrogate childbearing is another approach
to addressing the issue
of infertility.
Surrogate childbearing occurs
when a woman agrees
to become pregnant
for another woman
or
for a couple
who are usually childless.
Depending
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
and
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
of
who
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.
Nick,
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
that
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,
nerve,
or heart cells,
which might
then be used
to treat problems such
as diabetes,
Parkinson
and Alzheimer diseases,
spinal cord injury,
or metabolic disorders.
The availability
of specialized tissue
or
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
(NIH).
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.
Later
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,
ultimately,
new embryonic stem cell lines
will have
to be developed
(American Association
for the Advancement
of Science,
2002).
Positions
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
in
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?
Is
there justification
for using embryos remaining after fertility treatments?
The question
of
how an embryo
should be viewed-with status
in some way
as a person or
in some sense
as property
(and,
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
(Cameron,
2006).
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,
thalassemia,
and severe aplastic anemia.
However,
umbilical cord blood cannot be used
to treat leukemia
or inborn errors
of metabolism
in the same child
who donated it
at birth
(Moise,
2006).
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,
however,
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)
or
for another family member
who might need transplantation therapy
in the future because
of a genetic blood condition,
cancer,
bone marrow failure,
or inborn error
of metabolism,
for example.
In 2005 the Institute
of Medicine
(IOM)
completed a study
for the Health Resources
and Services Administration
(HRSA)
focused
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
(Kurtzberg,
Lyerly,
& Sugarman,
2005).
Legislation authorizing funding passed
in 2005.
Ethical issues associated
with cord blood banking include the following
(Smith & Thomson,
2000):
* Who owns the blood?
The donor?
The parents?
Private blood banks?
Society?
* 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?
Should
there be any ongoing assessment
of donors so that
if health problems develop,
recipients
can be notified?
* How
can the harvested blood be distributed fairly,
so
that it is available
to individuals
from all races,
ethnic groups,
and income levels?
Implications
for Nursing Practice
The complex ethical issues facing maternal-newborn nurses have many social,
cultural,
legal,
and professional ramifications.
Nurses,
like all healthcare professionals,
need
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,
participate
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,
coupled
with theoretical knowledge
about ethical decision making,
can serve nurses well
in dealing
with the many ethical dilemmas found
in health care.
STATISTICAL DATA
and MATERNAL-INFANT 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:
descriptive
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,
they
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.
Exactly
why
that trend has occurred cannot be answered
by simply looking
at these data,
however.
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,
use
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.
Inferences
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
(non-Hispanic)
women decreased,
whereas the number
of births
to black women remained essentially unchanged.
Births
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
(Hamilton,
Ventura,
Martin,
& Sutton,
2006).
Table 1-1 LIVE BIRTHS
and BIRTH RATES
by AGE,
RACE,
AND ORIGIN
of MOTHER:
UNITED STATES,
2003
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,
regardless
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.
5Data
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.”
NOTES:
Race
and Hispanic origin are reported separately
on birth certificates.
Persons
of Hispanic origin may be
of any race.
Race categories are consistent
with the 1977 Office
of Management
and Budget
(OMB)
standards.
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.
SOURCE:
Hamilton,
B. E.,
Ventura,
S. J.,
Martin,
J. A.,
& Sutton,
P. D. (2005,
October 28).
Preliminary births
for 2004.
Health E-Stats.
Hyattsville,
MD:
National Center
for Health Statistics.
Table 1-2 LIVE BIRTH RATES
and INFANT MORTALITY RATES
for SELECTED COUNTRIES
SOURCE:
Data
from The World Fact Book 2006.
Washington,
D.C.:
The Central Intelligence Agency.
Childbearing
by unmarrried women continued
to increase
in 2004,
reaching record highs-almost 1.5 million births-an increase
of 4%.
In fact,
35.7%
of all births were
to unmarried women.
Moreover,
these increases occurred
in all ages,
races,
and Hispanic-origin subgroups
(Hamilton,
Ventura,
Martin,
& Sutton,
2005).
The cesarean birth rate reached record levels,
increasing
by 6%
to 29%
of all births
in 2004.
Concurrently the rate
of vaginal birth after cesarean
(VBAC)
dropped 13%
from 10.6%
in 2003
to 9.2%
in 2004
(National Center
for Health Statistics
[NCHS],
2005b).
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?
Are
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).
However,
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
(Hoyert,
Heron,
Murphy,
& Kung,
2006).
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.
Table 1-3 INFANT DEATHS
and INFANT,
NEONATAL,
AND POSTNEONATAL MORTALITY RATES:
UNITED STATES 1982-2002.
(2005)
1Partially edited data processed
through January 2004.
SOURCE:
Health E-Stats.
Supplemental Analysis
of Recent Trends
in Infant Mortality.
www.cdc.gov/nchs.
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,
coordination
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.
Unfortunately,
information
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,
standards
of living,
nutrition,
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
to
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,
resulting
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.,
2006).
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,
intrapartal,
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?
Implications
for Nursing Practice
Nurses
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
of MATERNAL DEATHS
and MATERNAL MORTALITY RATES
for SELECTED CAUSES
by RACE:
UNITED STATES,
2003
*Figure does not meet standards
of reliability followed
by National Center
for Health Statistics.
SOURCE:
Hoyert et al.
(2006).
Deaths:
Final Data
for 2003.
National Vital Statistics Report,
54(13),
1-40.
Statistical information is available
through many sources,
including professional literature;
state
and city health departments;
vital statistics sections
of private,
county,
state,
and federal agencies;
special programs
or agencies
(family-planning
and similar agencies);
and demographic profiles
of specific geographic areas.
Most
of these sources are accessible via the Internet.
Nurses
who use this information
will be better prepared
to promote the health needs
of maternal-newborn clients
and their families.
EVIDENCE-BASED PRACTICE
in MATERNAL-CHILD NURSING
Evidence-based practice-that is,
nursing care
in
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,
client-centered,
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,
and
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
Unfortunately,
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.
However,
there is more
to evidence-based practice
than simply knowing
what is being tracked and
how the results are being used.
Competent,
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,
children,
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,
valid,
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,
therefore,
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
and
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,
standards
of care,
statistics,
and critical analysis skills.
These tools
can exist separately,
but
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;
looking
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
and
what the program content is;
looking
at national statistics identifying
when adolescents seek prenatal care;
talking
with local certified nurse-midwives,
physicians,
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,
volunteering
in local adolescent clinics,
developing
and teaching prenatal classes
for adolescents,
volunteering
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.
CHAPTER REVIEW
FOCUS YOUR STUDY
* 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,
especially
among children
and women-headed households.
* The nurse
who provides culturally competent care recognizes the importance
of the childbearing family’s value system,
acknowledges
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,
and
in directing the development
of quality nursing care.
* Informed consent-based
on knowledge
of a procedure
and its benefits,
risks,
and alternatives-must be secured
before providing treatment.
* State constitutions,
statutes,
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.
However,
some
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?
How
will informed consent be obtained and
by whom?
How
will confidentiality be ensured?
How
can the harvested blood be distributed fairly,
so
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
in
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.
EXPLORE MediaLink
http://www.prenhall.com/davidson
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.
Click
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:
Request
for Second Trimester Abortion
Applications:
Scope
of Practice;
Standards
of Care
Critical Thinking
CRITICAL THINKING
in ACTION
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,
weeks
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.
Depending
on the trimester
of the pregnancy,
you review the discomforts
or concerns
of the mother/family
and
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?
REFERENCES