Download MATERNITY NURSING in the 21st CENTURY

A GLIMPSE AT
MATERNITY NURSING
in the 21st CENTURY
K. L. Ringgenberg, RNC, MSN, WHNP
Shanghai Jiao Tong University SON
April 5, 2006
Maternity Nursing in the
21st Century
• Antepartum Care
• Intrapartum Care
• Technology in OB
“Partum”
• Parturition: birth
• Partum: regarding time period to the
birth
• Antepartum: before birth or prenatal
• Intrapartum: during the birth process
• Postpartum: after the birth (usually
regarded as the first 30 days)
Antepartum Care in the 21st
Century
• Care beginning before the birth
• “Prenatal” care
History of Antepartum Care
• Prior to 1925, no formal practice of
antepartum care.
• 2nd Century-warned against violent
movements to prevent ROM, sexual
intercourse harmful to pregnancy
• 1513-first published OB text (Germany)
• 1700s-forceps invented, male midwife
developed theories for midwives in London
• 1700s into 1800s-births attended by
female community in US due to price
History- continued
• 20th Century-at the turn of the
century, 50% of births in US
conducted by midwives
Home to Hospital-History
• 1900 <5% USA babies born in
hospital
• 1940 50%
• 1970 99%
• 2005 99%
Fast Facts-Maternal
• 1900-maternal death rate 6-9/1000 USA
• 40% of those deaths were due to
infection
• 2004-death rate at ~8-9/100,000 USA
• 1989-maternal death rate in China
95/100,000
• 2004-48.3/100,000
Fast Facts-Infants
• 1900-30% of infants in USA major cities
died before 1st birthday
• 2000s-infant mortality rate~7/1000 USA
• <1950’s-infant mortality rate 300/1000
China
• 2001-33/1000 in China (reportedly as
low as 5/1000 in Beijing and Shanghai)
20th Century Influences
• High infant & maternal mortality rates
• 1914-coined term “nurse midwife”
• Today-nurse midwife is defined as a RN
with an advanced certification and
master’s degree in midwifery
• 1925-Children’s Bureau in the US
recommended antepartum care to
decrease mortality rates
20th Century Influences
• 1965-Nurse Practitioner role (Peds)
• 1972-NP role expanded to OB/GYN
• 1989-US Public Health Panel examined
prenatal care-recommendations made
• 1950-2000-improvements in mortality
due to changes in meds, antibiotics,
blood products, nutrition-not prenatal
care itself.
21st Century- Major Shifts
caused by
• Managed care
• Rise of collaborative health care
teams
• Malpractice crises
• Increased concerns for antepartum
care and quality of care
• Internet and computer technology
21st Century- more factors
• Increased maternal age
• ART-assisted reproductive technologies
• Advances in genetic counseling and
prenatal diagnosis
• Evidence-based care
• Efforts to meet goals of Healthy People
2010 and Safe Motherhood Initiatives in
developing countries
• Rising awareness of CAM (complimentary
& alternative medicines)
Twins 4/1000
West Triplets 1/7,000-10,000
Skopec Quads
1/600,000
Intrapartum Care in the 21st
Century
• Care provided during the birth
process
• Vaginal Delivery
• Cesarean Section
Where do delivers occur?
• 96%-Hospital
• 2.4%-Birthing Centers
• 1%-Home
*Delivers in US by CNMs
Cesarean Sections
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C/S rates are at an all time high.
Rates vary from country to country.
Some examples:
Netherlands <10%
Great Britain 20%
USA
24-27%
HK
50% in private hospitals
China
~50% in some hospitals
The jury is still out!!!
Global Look
• 70% on average-births attended by
CNM in Western Europe
• 85%-Holland (which WHO
designates as ideal or #1 ranking)
• 10%-United States
• Refer to previous stats on
mortality/morbidities.
Nurse-Midwifery
• Midwifery model-care that safeguard the
birth process as natural and holistic.
• Medical (or illness) model-care is based
on birth is more of a disease state.
• Intrapartum/neonatal mortality rate
same for birth center or hospital
(term/low risk)
Certified Nurse Midwife
• Registered Nurse
• Advanced Practice Nurse (APN)
• Master’s degree in Nursing
• Specializing in Midwifery
• Credentialing necessary for state
licensing
Defining Attributes
• CNM-provides prenatal & gyn care to
normal healthy (low risk) women; do
delivers and postpartum care.
• Practice in hospital setting, clinics,
birthing centers and homes
• May practice independently or in
collaboration with a physician
CNMs associated with• Personalized care
• High-touch
• Low-tech
• Comforting care
• Alternative approaches
Competencies
• Obtain admission history & physical
• Assessments of mother and fetus
• Order or initiate tests, medications
or procedures
• Perform ongoing exams of labor
status
• Attend the delivery
Attending labor and birth
• Provide safe, satisfying care
• Patient and family are active
participants
• Informed consent
• Appropriate use of technology
Activities
• Evaluation
• Comfort
• Assistance
• Support
• Reassurance
• Management of complications
Settings
• Home
• Birthing Centers
• Hospitals-Labor, Delivery &
Recovery Rooms (LDR), LDRP
(post-partum), Single room
maternity care, Birthing rooms
Technology for the 21st
Center
• Birthing rooms
• Delivery rooms
• Operative suites
Birthing Suite
C-Section Rooms
Latest Technologies
• Electronic Fetal Monitoring (EFM)
• Ultrasonography
• Infusion pumps
• Electronic monitoring devices:
1. Non-invasive
2. Invasive
Fetal Surgeries
Electronic Fetal Monitoring
• Intermittent or continuous
assessment of fetal heart rate
(FHR) and uterine activity (UA)
• Goal- to assist in identifying the
fetus at risk
EFM
EFM
• External (indirect) method
• Internal (direct)
Antepartum testing with
EFM
• NST-non-stress test
• CST-contraction stress test
• BPP-biophysical profile
All assess fetal well-being
Intrapartum EFM
• External-tocodynamometer and
transducer
• Internal-spiral electrode and
intrauterine pressure catheter
• Fetal pulse oximetry
Emerging EFM Technology
• Computer analysis
• Lack of clear definitions and
standards at this point of fetal
heart rate patterns, however, due
to come out this year
Electronic Health Record
• Computers
• Paperless charts
• Integrates all aspects of
assessment, intervention and
evaluation
Doppler
Ultrasonography
• Done at all stages of pregnancy
• Transvaginal or transabdominal
approach
• Done for maternal or fetal
indications
• Done in office, clinic, mobile
centers, ob unit, L & D
Indications
• Maternal diseases
• Multiple gestations
• Fetal growth
• Establishment of fetal age
• Placental location and grading
• Assess fetal well-being (BPP)
• Pre-term labor-cervical lengths
It’s a Girl!!!
3-D & 4-D Ultrasound
3-D Early Gestation
S/D Ratios
Pulse Oximetry
V/S Monitors
Electronic B/P Monitor
Critically Ill OB
• Continuous cardiac monitoring
• Invasive hemodynamic monitoring
• CVP
• Arterial lines
• Pulmonary artery lines
• Ventilator
OB Critical Care Unit
Flight Nurses
Flight Nurse
Genetics
• Human Genome Project
• Relationship to Maternity Nursing
• Advanced maternal age
• Patterns of inheritance
• Prenatal testing
• Genetic counseling
• Ethics and other
Telemedicine
• Telemetry
• Monitoring-FHR
• Computer
• Ultrasound images
• Telephone
Informatics
• IT
• Computers
• Patient access to information
• Nursing informatics
Automated Medication
Dispensing Machines
• Cut down on errors
• Bar codes
• Chart medications
• Labor saving
• And more
Summary
• Past, present, future antepartum
care aspects
• Intrapartum care in the 21st Century
as it relates to nursing and CNM
• Technology today in maternity
nursing with a glimpse into the
future as well
What is in your nursing
future for the 21st
Century?
Questions or comments?