Maternal Child Nursing – Lecture 1

Childbearing in 20th Century

Pre 1900’s: Birth @ home with assistance of midwives. Physicians involved for serious problems.

“natural event” Maternal & infant mortality high. Main causes of maternal death: post partum

hemorrhage, post partum infection (aka puerperal sepsis or “childbed fever”), toxemia

Primary causes of infant death: prematurity, dehydration d/t diarrhea, & contagious diseases.

1900 -1930’s: Obstetrical training of physicians & use of forceps brought deliveries to hospitals.

1940’s - 1950’s: 80% women gave birth in hospitals. Male physicians . No midwives. Heavy drugs (demerol) “twilight sleep” for labor & delivery.

General for C/S Fathers not allowed in DR; “waiting rooms” to “protect

them from gruesome reality of childbirth”.

Dr. Ferdinand Lamaze (France) “childbirth without pain” AKA Lamaze Method. Breathing patterns, relaxation techniques, concentration on focal point. “Monitrice” aka Doula/coach. Lamaze method popular in US - 1950’s.

Dr. Bradley [USA-1955] supported natural childbirth. No anesthesia, fathers in DR, breastfeeding. 12 weeks of classes.

1960’s: Women wanted ^ control over their bodies. Took childbirth education classes & FOB present. Hospital deliveries were norm.

1970 – 1980’s: Change from cold, sterile hospital environment to warmer setting [family present].

Birthing rooms “Epidural anesthesia” – women awake for vaginal & C/S. Natural childbirth still popular – but more women opting for pain relief during labor & delivery. Fathers present for

most types of deliveries except C/S. “Rooming in” popular. M/B together for entire hospital

stay.

Present: Focus is “family”; fathers active participants. Analgesia/anesthetic agents monitored/used more. Shorter hospital stay; Sibling visits encouraged. Midwives or physicians used. Infant stays with mother in DR to initiate breast feeding. Childbirth Ed popular- allows couple to make informed

choices about labor & delivery experience. "Family-centered maternity care" popular marketing

strategy. ^ fear of pain & perineal trama. More C/S’s as a result. C/S rate ^ from 10% 1970 – 40% 2009 in USA. Less episiotomies.

Goal of maternity staff: promote meaningful experience for childbearing family Ensure health of mother & child. Birth is significant life event. Honor birth wishes of couple. Family centered care respects autonomy of family

members; approaches childbirth decisions in non-judgmental manner.

FOCUS: teach new mother self/infant care. “Independent” function of RN

Government Programs High rates of maternal & infant mortality in early 1900’s

among poor set stage for federal involvement in maternity care.

In 1921, Sheppard-Towner Act provided funds for state-managed programs for mothers & children.

Other programs followed. Partially solved mortality problem; distribution of health

care remained unequal. physicians practiced in urban/suburban areas; women in

rural & inner city less access to health care. Ongoing problem of unequal health care allowed nurses

to expand their roles for advanced practice.

1935: Social Security Act established system of grants for health & welfare programs. Included aid for dependent mothers/children.

1963-1964: mandate established thru Children's Bureau of DOH & Human Services to establish 2 Maternity/Infant Care Projects in each state.

In New York City, a Maternal, Infant & Reproductive Health Program began.

1984, Bureau of Maternity Services & Family Planning: * Community-based health education programs. Since then, high-risk communities have comprehensive

case management services, intensive counseling/education/home visits.

1972: Supplemental Food Program – “WIC” “Women, infants, & children” created as 2-year

pilot program [1972] thru amendment to Child Nutrition Act of 1966. Permanent in 1975.

established during time of ^ public concern about malnutrition among low-income mothers & children.

delivers early nutrition & health intervention during critical times of growth & development

Used as prevention tool

4 criteria:

Categorical :

Women:

1) pregnant

2) postpartum (up to 6 mos > delivery)

3) breastfeeding Infants -1st birthday. Children-5th birthday.

Residential : live in State in which they apply

Income: income at or below State standard

Nutrition risk: medical and/or dietary-based conditions.

ie. Anemia, underweight

How many get WIC? > 7 million people each month (current) In 1974, [first year] 88,000 people participated. Children largest category of WIC participants. WIC program available in each State, District of

Columbia, 33 Indian Tribal Organizations, Puerto Rico, Virgin Islands, American Samoa, and Guam.

WIC foods include: iron-fortified infant formula and infant cereal, iron-fortified adult cereal, vitamin C-rich fruit and/or vegetable juice, eggs, milk, cheese, peanut butter, dried beans or peas, tuna fish and carrots. Special infant formulas.

PCAP Prenatal Care Assistance Program - Medicaid program run by NYSDOH prenatal care for uninsured mothers at/below poverty Medicaid Obstetrical and Maternal Services (MOMS)

provides complete pregnancy services where PCAP centers are not located. No cost to participate.

Offers: Routine pregnancy check-ups, lab work, specialists Hospital care during pregnancy/delivery HIV counseling/testing Help in applying for WIC & low or no cost health ins. Full health care for mom until 2 months after delivery Health care for baby for 1 year after birth Family planning services

Suffolk County Perinatal CoalitionA community based organization dedicated to:

Educating expectant mothers to deliver healthy babies. Promoting community's goal to achieve healthy birth

outcomes, prevent infant mortality, low birth weight & prematurity throughout Suffolk County.

Works with SCDOH. Founded 1985 by coalition of maternal health providers

committed to reducing infant mortality & birth complications.

Suffolk Perinatal Coalition475 East Main Street Suite 20

Patchogue, NY 11772 Tel: 631.475.5400; info@scpc.net

Statistics Birth Rate: # live births/1,000 population.

2007 – U.S. birth rate increased (14.3 per 1,000) Teen birth rate increased (last 2 years) – 43/1000 aged 15-19

^ birth rates for women aged 35 to 39 (42.4 per 1000) Women aged 40 to 44 (8.2 per 1000)

Infant Mortality Rate: deaths of infants < 1 yr./1,000 live births. 1950 @ 18%; 2000 @ 6.8%. ^ 2005 @ 6.86

Most significant measure of maternal/child health & adequate prenatal care. USA ranks 29th. PTL = 36.5% of all infant deaths. Congenital defects & VLBW are 2 leading causes.

Neonatal mortality: deaths of infants < 28 days of age/ 1,000 live births. Rises slightly each year d/t premies being born earlier.

Maternal Mortality: deaths from any cause R/T pregnancy & 42 days PP /100,000 births.

2005 = 15.1/100,000 live births.

1900’s rate 600/100,000 live births. African American women’s rate of death in US was more than 4 times rate for white women (2001)

Overall decline attributed to improved prenatal, intrapartal, postpartum care & specialized healthcare personnel.

Healthy People 2010 Goals National agenda to improve health care Distribute health care equally among all ethnic/racial groups Earlier prenatal care High technology [3rd level NICU] < 32 wks. US ranks 23rd for infant mortality d/t Hi rate LBW infants

83.4% - prenatal care in 1st trimester (2002) 3.9% - prenatal care in 3rd trimester or NONE at all [1998] 8.1 million children without health insurance (2007) 43.9 million people without health ins (2006) 27.4% children covered by Medicaid, & other govt programs African Americans, Hispanic, and Native American women less

likely to receive early and adequate prenatal care

Standards of Nursing Care Standards for Nursing care of women and

children set by AWHONN: The Association of Women’s Health, Obstetric, & Neonatal Nurses.

Assesses family for strengths/needs Encourages use of community resources; “rooming in” Respects diversity in families; Encourages family-oriented care Promotes using evidence-based practice as basis for nursing

interventions [research studies]

ANA – standards of practice for maternal-child nursing 2010 National Patient Safety Goals JCAHO

Ethical IssuesMaternity Nursing = family-centered. Conflicts with following topics:

Abortion (fetal rights vs. rights of mother esp. with 2nd & 3rd trimester AB’s)

Embryonic Stem Cell Research Cord Blood Banking Terminating Life Support - “ To resuscitate or

not” with very young fetus < 23 wks. Not viable. Looks at “quality of life” issues.

Conception issues involving surrogate mothers, embryo transfer, cloning.

Reproductive Assistance Technology [ART]

Ethical Issues

RN can help clients face difficult decisions by providing factual information, supportive listening, by helping family clarify values.

Maternal health care has both legal & ethical considerations more than with other areas of healthcare b/c of presence of both fetus & mother

The Family “Family” - U.S. Census Bureau 2008 - “2 or more

people joined by marriage, birth, or adoption living together”

How well family works together against potential threats depends on its structure & function.

2 Basic Family Structures: Family of Orientation: Family one is born into. Family of Procreation: Family one establishes.

Specific Family Types

Nuclear – traditional husband, wife & children Extended – includes nuclear plus grandparents, aunts,

or uncles, etc. living together.. Advantages: ↑ support, ↑ childcare options, ↑ role models Single-Parent : Approx. 50-60% of families w. school-

age children; 15% headed by males. D/T ^^ in divorce & common practice of women raising children alone.

Disadvantages: Lack of support (childcare) Limited finances Role strain – trying to fulfill maternal & paternal roles Mental & physical strain

FAMILY FUNCTION:

“ Ability to meet needs of its members thru developmental transitions (grows/changes).”

*Each new generation adapts values & traditions from previous generations.

*When doing family assessment - identify behaviors that are strengths and deficiencies.

FAMILY TASKS:

8 tasks to being successful family unit: Physical maintenance (food, shelter, health care) Socialization of family members (interaction outside family) Allocation of resources (meeting family needs) Maintenance of order ( communication, family rules) Division of labor ( income, childcare, etc.) Reproduction/release of family members (progression from

infancy thru young adulthood) Placement of family members into larger society

(community activities, church, political group) Maintenance of motivation & morale (family pride)

FAMILY LIFE CYCLES: Duvall 1977Oldest child marks stage family is at Marriage & family Early child-bearing family Pre-school child family School-age child Adolescent child Launching Center (most difficult- disruption of family

unit)

Family of middle years (empty nest) Family in retirement age

Community Assessment Look at surrounding community - tells how vulnerable it

is to disease & mental/social problems. Poverty level & many young children strongly assoc. w.

^ community health needs. Increased abuse in families. D/t ^ stress & better reporting.

NURSE RESPONSIBILITIES: Be aware that it exists in all communities. Careful screening of abuse

Cultural Competency(March of Dimes)

Immigration to U.S. ~ 1 million immigrants come to U.S. each year (U.S. INS,1991). [Immigration & Naturalization]

More than half are women of childbearing age (U.S. INS, 1991) 2006-2008 -12.5% FOREIGN BORN in USA [1.25 in every 10] (National Center

for Cultural Competence, 1999).

What is Cultural Competence?

Providing services, supports and assistance: Responsive to beliefs, interpersonal styles, attitudes, language and

behaviors of individuals with greatest likelihood of ensuring maximum acceptance and participation.

Respect for individual dignity, personal preference and cultural differences.(Developmental Disabilities and Bill of Rights Act of 2000)

Suffolk County is Very Diverse

~ 1.5 million residents 8% African American 13% Hispanic/Latino 4% Asian American 1% American Indian 74% White

SCDOH Clinics - even more diverse

55% Latino/Hispanic 17% Black 2% Asian (1% Asian Indian) 19% White

2009 3rd quarter Health Information Systems

Importance of Cultural Competence..

U.S. demographics are changing. Health disparities exist between ethnic groups Health care organizations require increased,

documented cultural competence. Cultural competence enriches professional nursing

practice.

What is Culture? Distinct way of life that characterizes particular

community of people. Includes learned practices, beliefs, values, customs

passed through generations. Provides sense of identity

Acculturation Integration into mainstream culture Depends on age at time of arrival, reason for moving to

new area and residence in predominantly ethnic neighborhood

Generally takes three generations in USA (Spector, 2000)

Ethnocentrism Ethnocentrism belief that one’s own culture is best. Providers must be aware of own ethnocentrism. Cultural Perspectives depends on if you are member of culture or observer of

culture

Cultural Traditions Functional tradition – enhances health and well-being Neutral tradition neither enhances nor harms health and

well-being Non-functional - potentially harmful

Cultural Characteristics

Individual vs. group identity Decision-making

Eye contact Being polite

Family oriented Time orientation

Father’s participation at birth Nutrition

No Male hcp Pregnancy as healthy

natural state

Female Genital Mutilation: Curb sexual desire of girls/women and preserve "sexual honor" before marriage. It is irreversible and extremely painful, and is usually done to young girls.

Instruments Used

Common Cultural BeliefsHot and cold: Illness d/t imbalance -causes body to be

hot/cold. Needs balancing to correct illness. Chinese theory “ying/yang” – similar Pregnancy- “hot”: consume cold foods Post Partum- “cold”: consume hot foodsExample: Vietnamese culture: spinach, melons, beans

[pregnancy] and soup w. chili peppers, salty fish, meat w. herbs & wine [post partum]

Iron supplement = considered “hot” Found in parts of Asia, India, Latin America

Evil Eye Theory: 80% world’s population believes in this. Hispanics term “mal ojo” - belief that certain actions invite evil spirits to cause illness/death.

Populations and Conditions African American--Sickle cell disease Amish--PKU, hemophilia B Greek--Thalassemia Jewish--Tay-sachs, Gaucher’s disease Native American--Type 2 diabetes mellitus

Note: Conditions not limited to a single population group.

Ways to Relate to Other Cultures

Common practices Avoiding people from other cultures Refusing to recognize cultural differences Recognizing differences, but feeling own way is

superior (ethnocentrism) Best practice

Acknowledging and seeking to understand cultural differences

Cultural Assessment

Where were you born? How long have you lived in the

United States? Who are your major support

people?

Childbearing Assessment

What are your religious practices? Food preferences?

Economic situation? What languages do you speak

and read?

How would you like to manage labor pain?

Who will provide labor support?

Who will care for the baby? Do you use contraception?

What does childbearing represent to you?How do you view childbearing?Are there any maternal precautions or restrictions?Is birth a private or social experience?

Assessment Techniques Use conversational approach. Ask open-ended questions. Integrate cultural and childbearing assessments. Listen with interest. Nonjudgmental

Interpreters: Interpreters communicate verbally.

Should be female Should not be family member

Can work with written communication. Maintain strict confidentiality. Do not paraphrase Use Translator Phone