Foundations of Maternity, Women’s health and child health nursing ch 1


Foundations of Maternity, Women’s Health and
Child Health Nursing Chapter 1 Maternity and pediatric care and nursing has
changed over the years. These changes are made to provide better patient
outcomes. Delivering babies has really come a long way. Many years ago, babies were delivered by what
they called “granny” midwives. These were women were also known as lay midwives. They basically learned what they needed to
do by being an apprentice and following an experienced midwife and learning on the job. They would come to the house, have very little
medical equipment and hope for the best. During this period, they had a high rate of
maternal and infant deaths. There are still midwives who deliver babies
but the majority of them have medical training and hold nursing degrees. A few exceptions to this include the Amish
population and other underprivileged countries. The emergence of medical management meant
most women now we’re delivering in the hospitals. During this transition, women didn’t have
much say in their care. They came to the hospital, weren’t given
many choices on what would happen. Fathers waited in the waiting room so the
women spent most of their labor alone. Once the baby was delivered, it was whisked
away and kept in the nursery most of the time. Bonding between the parents and infant did
not occur. This did help decrease the maternal and infant
mortality rates but not as quickly as it should. The government developed many maternal-infant
programs to help prevent or reduce these numbers. Table 1-1 lists a few of these. Beginning in the 1950’s woman and families
wanted more of a say in their birthing experience. This brought about the development of family-centered
maternity care. We need to include the whole family in the
care and the decisions. It is important as maternity nurses to evaluate
who are the support people and what type of involvement will they have? We need to educate the family and not just
the woman. Today there are options of where to give birth. Most women still opt to go to the hospital
to deliver. In the hospital you will typically find two
options. First is the labor, delivery and recovery
rooms also known as LDR’s. Once it is determined the woman is in labor,
she will labor, deliver and stay in there room until her recovery is completed. This is typically 1-4 hours but can vary. The second option are the labor, delivery,
recovery, and postpartum rooms. This means the room they start out in for
labor, is the room they stay in until discharge. Many hospitals do have the LDRP’s. The advantage is less interruption of bonding
time by having to move. The rooms tend to be decent size so that helps
accommodate visitors. One disadvantage is that there still is the
change they will have to move. Most hospitals with the LDRP’s still have
an overflow area of rooms so if they get busy, they still may have to move. Birth centers are free- standing buildings
not connected to a hospital. They are for low risk woman and many centers
also provide gynecological services. Care if often done by CNM’s and they will
provide their aftercare as well. The environment is more family-friendly, home-like
and typically are less expensive. The biggest disadvantage is they are not set
up for emergencies. If something happens, they will be transferred
to a hospital and most likely their midwife will not have privileges there so they would
have a different provider. Many times the women go home within 12 hours
after delivery if there are not complications. Home births still occur. Most are done by CNM’s but there are still
a few lay midwives out there as well. The advantage
is the family can be present ,the woman tends to feel more comfortable in her own home and
bonding takes place immediately. Of course you have to be low risk to do this. Disadvantages is there is no medical back
up. If something goes wrong, you have to wait
for an ambulance to get there to transport to the hospital. Can be a very scary time if this is going
on. What is family-centered care? It is exactly what it says. We are caring for the entire family. We include them in decision making, education,
plan of care .When you look at a pediatric patient, you have to include the whole family. If you have a 4 year old child with asthma,
you have to address the home environment with whomever lives in that home or also, where
that child spends most of their day (day care, grandmas’s etc). You can’t expect a 4 year old to know that
when it is extremely humid outside that they need to stay inside. You can’t expect them to know to stay away
from smoke, cleaning products, or whatever triggers them. Remember, family doesn’t mean just blood
relatives. Look at who are the important people in the
care of that child. We do it to have better patient outcomes. It can increase patient compliance as well. It benefits all involved. Healthy People 2020: Some examples include;
Improve the health and well-being of women, infants, children, and families
Improve access to comprehensive, quality health care services. Improve the healthy development, health, safety,
and well-being of adolescents and young adults (AYAs). Document and track population-based measures
of health and well-being for early and middle childhood populations over time in the United
States Improve pregnancy planning and spacing, and
prevent unintended pregnancy Increase immunization rates and reduce preventable
infectious diseases Cost containment basically means that patients
are charged one fee for the services they received. For example: it used to be that every item
a person used while in the hospital had a sticker on it and they were charged for that
item. For example: if they needed a foley, they
were charged for the foley. Now it is determined what the average cost
would be for a vaginal or c-section delivery and that is how much the insurance company
will pay. If you have a nice “normal” vaginal delivery
with no complications to mom and baby then things works out well. But lets say baby is having some feeding difficulties
so the pediatrician wants them to stay an extra night. The hospital probably won’t get any more
money for that stay. Maybe the insurance company is going to pay
$3500 for an uncomplicated vaginal delivery. That is based on a 24 hour hospital stay. Now if they have to stay longer the insurance
company may not pay more. This set rate is determined by the DRG (diagnosis-related
groups). This is how they code the hospital stay. That is why your documentation is really important. If you are always documenting that the baby
is breastfeeding fine, no help is needed with latching, etc then the insurance company thinks
everything is fine. It is crucial your documentation is exceptional
as a nurse .So of course if they hospital (and many times the providers) are you only
going to get a set amount, they are anxious to send them home. It is like if you were going to get paid $100
to clean your neighbors house. Wouldn’t you want to to have it cleaned
in 2 hours instead of it taking you 8 hours to clean? You feel it was worth your time. Same type of concept here. The effects of this is they may send moms
and infants home at the 24 hour mark and many times problems or concerns may not arise in
that first 24 hours .So by sending them home early, crucial assessment data could be missed. Evidence based care. Hopefully you are all familiar with this. It affects every aspect of nursing. As nurses you must be following evidence based
care while caring for your patients and this includes areas of early discharge due to cost
containment. Home care for pregnant women, infants and
children have been increasing steadily over the past few decades. Trying to manage chronic or acute problems
at home is what is driving this increase. Most patients prefer to be home instead of
the hospital setting. Some examples can be triage services, home
nursing, lactation consultants, Advantages include that the family can stay
together, treatment is in their own home. Many times it helps reduce the cost for driving,
missing more work, etc. Community care is crucial to both the OB and
Peds population. One reason community care is so important
is because access to care is a big problem in the United States. This is correlated with having insurance. The Affordable Care Act has helped with some
of this but there are still many that do not have insurance or they are under insured . They
have the insurance but can’t afford deductibles, or some providers will only accept certain
insurances. Many rural areas just do not have enough providers
for the whole community. There are public health insurance programs
to help with some of these issues. Preventive health is an area that has a lot
of focus on now. This can include dental clinics, immunization
clinics and any other program that will help prevent against health issues. There are a variety of healthcare assistance
programs out there as well to help mainly with families of the lower socioeconomic group. WIC (Women, Infants and Children) is a very
popular resource available to help with nutritional aspects for pregnant women, infants and in
most cases, children up to age 5. March of Dimes is another example that finds
ways to help reduce premature births. Maternal and infant mortality has increased
since better sanitation conditions, use of antibiotics and medical equipment. The statistic in the last few years have not
changed much but there is a higher incidence in nonwhite groups. The five leading causes of infant mortality
includes congenital abnormalities, deformations and chromosomal abnormalities, disorders related
to low birth weight, newborn problems related to maternal complications, sudden infant death
syndrome and unintentional injury Adolescent births are at the lowest levels
but these infants are still at risk for many things. This includes: low birth weight or preterm
infants. Also greater risk for dying in infancy than
older mothers. Death rates of children have been decreasing. Table 1.3 shows the leading cause of death
in children. Info for morbidity is not collected as frequently
as mortality rates. Morbidity is more common in lower socioeconomic
classes and also the ones who have poor access to healthcare
Ethical dilemmas is a situation in which no solution appears completely satisfactory. Some areas of ethical concern includes elective
pregnancy termination, fetal injury for OB and for peds includes withholding or ceasing
life-sustaining treatment and terminating life support. Facilities have ethical teams to help with
these issues when need be. There are many social concerns in the OB/Peds
environments. One of the biggest concerns is poverty. This can lead to inadequate access to healthcare
which can be the start of many problems. Health concerns are not identified, lack of
education that can occur at visits, non-compliance, not following up and no money for medications
or preventive measures are a few of the issues that poverty can lead to. Homelessness used to be just single people
but homeless families are on the increase. Poor living conditions can lead to medical
problems. Nutrition is a huge problem in the homeless
environment. Either they are not eating adequate amounts
or what they are eating could be contaminated causing illness. Adequate prenatal care is main way to decrease
mortality rates and preterm or low birth weight. It is recommended that woman now start pre-pregnancy
counseling to help prepare her for pregnancy. Proper weight, identification of underlying
conditions and adding folic acid to the diet prior to pregnancy can decrease infant mortality
rates. Violence is always a concern for the OB/Peds
population. Domestic or child abuse are concerns. Currently there is an increase in school injury
for the peds. This can include bullying and school violence. There are some legal issues with every form
of nursing. Safeguards for healthcare has three categories
to determine how the law views nursing practice. These include; Nurse practice act which determines
the scope of practice for each state for RN’s, Standards of care which are guidelines set
by professional associations for that areas of nursing. For OB they use the Association of Women’s
Health, Obstetrics and Neonatal Nurses known as AWHONN. This helps determine plan of care for many
patients. The third safeguard are hospital policies. Following all of these will ensure you are
providing standard of care to all of your patients. Accountability includes knowing the laws that
revolve around patient care, also keeping current in all aspects of nursing (this includes
your license, Continuing ed requirements, competencies, etc). Malpractice includes negligence by professionals
which includes nurses. You can be sued. There is a lot of literature out there regarding
if nurses need their own malpractice insurance. That is a decision you make on what you feel
is best. Prevention of malpractice includes following
all of the safeguard for healthcare. OB is one of the highest areas for malpractice. Two areas of highest liability include fetal
monitoring which we will talk about in future weeks and informed consent. Making sure all info is provided to the patient,
they understand what is happening and they are competent to consent. Documentation is the key to all of these areas. I cannot emphasize this enough. As an OB nurse, you can be pulled into court
up to 18 years after birth. Do you think you will remember? Not a chance. Precise documentation is crucial. EMR has many advantages but the biggest downfall
to using EMR is nurses just fill in the boxes and don’t make narrative notes like they
should. Remember, if it is not charted, it is not
done even if you did it. Maintaining expertise is another area of legality. Continuing ed is a form of maintaining expertise. You need to stay on top of current trends
and evidence based practice. If you get pulled into court you cannot say
you didn’t know what the standard of care was for a condition. It is your responsibility to stay on top of
those.

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