Murray: Foundations of Maternal-Newborn and Women's Health Nursing, 5th Edition

Chapter 01: Maternity and Women's Health Care Today

Instructor’s Manual

OBJECTIVES
1.	  Describe changes in maternity care, from home birth with lay midwives to the emergence of medical management.
2.	  Compare current settings for childbirth both within and outside the hospital setting.
3.	  Describe settings for childbirth both within and outside the hospital setting.
4.	  Identify trends that led to the development of family-centered maternity care.
5.	  Describe current trends that affect perinatal nursing and women's health nursing, such as cost containment, outcomes management, evidence-based practice, community-based care, advances in technology, and increased use of complementary and alternative medicine.
6.	  Explain changes in family structure and discuss their impact on family functioning.
7.	  Compare Western cultural values with those of differing cultural groups.
8.	  Describe the effect of cultural diversity on nursing practice.
9.	  Discuss the downward trends in infant and maternal mortality rates, and compare current infant mortality rates among specific racial groups and nations.

Outline/Lecture Guide
 I.	Historical Perspectives on Childbearing
A.	"Granny" midwives
 	B.	Emergence of medical management
 	1.	Significant discoveries led to changes in maternity care
 	2.	Passive role for woman in childbirth
	3.	Hospital births hindered bonding
	4.	Technologic advances have decreased mortality slowly
 	5. 	Consumer demands led to additional changes
 	C.	Government involvement in maternal-infant care (Table 1-1)
 	1.	Federal funds used to improve maternity care
 	2.	Inequitable distribution of health care
 	D.	Effects of consumer demands on health care
 	1.	Consumers insisted on involvement
 	2.	Childbirth methods helped women regain control
3.	Awareness of benefits of extended parent-newborn contact
4.	Family-centered maternity care became the standard of care
         E.  Development of family-centered maternity care
	1.	Family-centered care adapts to physical and psychosocial needs of the family
	2.	Fosters family unit
	3.	Basic principles
		a.	Childbirth is normal, healthy event in family life
		b.	Childbirth affects entire family
		c.	Families are capable of making decisions about care
	4.	Increased nursing responsibility
 II.	Current Settings for Childbirth
 	A.	Traditional hospital setting
 	1.	Mother and infant separated after birth
 	2.	Setting impersonal and uncomfortable
 	3.	Hospitals began facilitating family participation
 	B.	Labor, delivery, and recovery rooms (Figure 1-1)
 	1.	Common alternative setting
 	2.	Significant others allowed to be present
 	3.	Transferred to postpartum unit after birth
 	C.	Labor, delivery, recovery, and postpartum rooms
 	1.	Family remains in same room until discharge
 	2.	Many have overnight accommodations for father or other support person
 	D.	Birth centers
 	1.	Provide maternity care to low-risk women
 	2.	Provide prenatal and infant care classes 
 	3.	Provide follow-up care 
 	4.	Less costly than traditional settings
 	5.	Not always equipped for emergencies
 	E.	Home births
 	1.	Malpractice insurance for midwives attending home births difficult to obtain
 	2.	Keep family together in a familiar environment
 	3.	Siblings not separated from their mother
 	4.	Bonding unimpeded by hospital routines
 	5.	Mother actively plans and prepares for birth experience
 	6.	Must be low risk of complications
 	7.	Must transfer to hospital if complications occur
 	8.	Must recover without professional help available in the hospital

 III.	Current Trends in Maternity Care
 	A.	Cost containment
 	B.	Diagnosis-related groups 
 	1.	Hospitals benefit by shortening length of stay
 	2.	Similar system used by Medicaid and other insurance companies
 	C.	Managed care
 	1.	Alternative health care delivery systems: HMOs (health maintenance organizations) and PPOs (preferred provider organization) 
2.	Initiated strategies to control costs
D.	Capitated care
	 1.	The payer of the health insurance pays a set amount of money each year to the primary care physician (PCP)
2.	Advantage: Payers can accurately budget for a year
3.	Disadvantage: Consumers lose freedom of choice regarding PCP; may have restrictions on diagnostic tests and referrals 
E.	Effects of cost containment on maternity care
 	1.	Length of stay reduced to 48 hours, cesarean sections to 96 hours
 	2.	Some mothers or infants have developed problems after discharge
 	3.	Legislation mandates stay of at least 48 hours
 	4.	Short stay decreases available time to prepare parents for discharge
        F.	Case management
	1.	Services coordinated by case manager to provide quality and manage cost
	2.	Requires interdisciplinary, collaborative approach 
 	G.	Outcomes management
 	1.	Identify client outcomes
 	2.	Focus care on meeting identified outcomes
 	H.	Clinical pathways (Figure 1-2)
 	1.	Guidelines to define expected client outcomes
 	2.	Collaborative effort of all professionals involved in care
 	3.	Variances do occur
	a. 	Positive variance when client progresses more rapidly
	b. 	Negative variance when progress is slower than expected
	c. 	Variance is analyzed and plan adjusted
 	4.	Use of clinical pathways
	a. 	Not meant to teach nursing skills and procedures
	b. 	Student learning needed before using clinical pathways in actual client care
I.	Evidence-based practice
1.	Nurses and other professionals base assessment and care on research data rather than tradition or habit
2.	Failure to incorporate hard evidence into nursing practice may have numerous undesirable effects
 	 J.	Community-based perinatal care
 	1. 	Community-based health care increasing in all practice areas
	2.	Nurses in community setting need broad array of skills
	 K.	Common types of perinatal home care
1.	Antepartum home care
a.   Some common high-risk conditions treated at home include preterm labor, hyperemesis gravidarum, bleeding, premature rupture of membrane (PROM), hypertension, and diabetes
2.	Postpartum and neonatal home care
	a.	Services included may be telephone calls, home visits, information lines, and lactation consultations
3.	Home care for high-risk neonates
a.	Infants that are preterm or have low birth weight or congenital anomalies may require special home care
b.	 Coordination of care for high-risk newborns is a major challenge
	 L.	Standards of practice for perinatal nursing
1.	Community-based care must meet guidelines for practice established by the agency or appropriate organizations
2.	Agency standards must comply with established national standards
3.	The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) is recognized as the national professional organization for perinatal services
4.	Community-based agencies must also abide by standards of federal and state regulatory bodies (Occupational Safety and Health Administration [OSHA], Food and Drug Administration [FDA], Centers for Disease Control and Prevention [CDC], etc.) 
        M.	Legal standards
	1.   Nurses must be aware of rules, regulations, and scope of practice
2.   Nurses must also abide by standards of federal and state regulatory bodies (OSHA, FDA, CDC, etc.)
 	N.	Advances in technology
 	1.	Perinatal care is constantly changing
 	2.	Instant access to online information
 	a. 	Nurses need to know how to use computers and other advances in technology
	b.   Need to learn how computers can help organize and facilitate nursing               practice
	 O.	Complementary and alternative medicine categories (Table 1-2)
	1.	Complementary and alternative medicine (CAM) is becoming more common; in 2002 nearly 75% of the population used CAM
2.	These therapies may be used alone (alternative) or in addition to
	conventional medical therapy (complementary)
	3.	Safety and delayed care are concerns with the use of CAM
	4.	Nurses may find that their professional values do not conflict with many of the CAM therapies

 IV. The Family (Table 1-3)
 	A.	Traditional families
 	1.	Couple views parenting as a major priority
 	2.	Motivated to learn
 	3.	Single-income families
	a. 	Father usually is sole provider
	b. 	Mother homemaker and caregiver
c. 	Minority of nation's families today
 	4.	Dual-income families
	a. 	Family dependent on two incomes
	b. 	Creates stress on parents
	c. 	Reliable child care a major issue
 	B.	Nontraditional families
 	1.	Unique structure
 	2.	Require information about parenting
 	3.	Single-parent families
	a. 	Single parent functions as provider, homemaker, and caregiver
	b. 	More likely to live below poverty level
	c. 	Nurses may be primary source of information about health care
 	4.	Blended families
	a. 	Divorced or widowed parents remarry
b. 	May have children with each other: "yours, mine, and ours"
	c. 	Differing expectations of parenting can cause family conflict
 	5.	Extended families
	a. 	Members from three generations under one roof
	b. 	Vulnerable to generational conflicts
 	6. 	Same-sex parent families
	a. 	Recognized increasingly in the United States
	b. 	Face challenges from the community
 	7.	Adoptive families
	a. 	Become parents without gestational period of adjustment
	b. 	Need information and support 
 	C.	High-risk families
 	1.	Those below poverty level
 	2.	Headed by a single teenage parent
 	3.	Have unanticipated stress
 	4. 	May require specialized services
 	D.	Characteristics of a healthy family
 	1.	Communicate openly with one another
 	2.	Remain flexible in role assignment
 	3.	Adaptable and not overwhelmed by change
 	4.	Volunteer assistance without waiting to be asked
 	E.	Factors that interfere with family functioning
 	1.	Lack of financial resources
 	2.	Absence of adequate family support
 	3.	Birth of a child with special needs	
 	4. 	Unhealthy habits
 	5.	Inability to make mature decisions related to infant care

 V.	Cultural Perspectives in Childbearing
 	A.	Cultural values guide thinking, decisions, and actions of a group
 	1.	Cultural beliefs can create conflict
 	2.	Culture consists of visible and invisible layers (Figure 1-3)
 	B.	Implications of cultural diversity for perinatal nurses
 	1.	Awareness of culture as a significant influencing factor in childbirth
 	2.	Nursing practice in the United States based on Western cultural beliefs
 	a. 	Democracy is a value not shared by all cultures
	b. 	Individualism conflicts with values of many cultural groups
	c. 	Cleanliness is an obsession not valued by all cultures
	d. 	Some cultures mark time by different standards
	e. 	Technology may intimidate families
	f. 	Health is not a major emphasis in all cultures
	g. 	Other societies place less value on wealth 
 	C.	Communication may be a source of conflict
 	1.	Language is a barrier to health care for Southeast Asians
	a. 	Numerous tribal languages are spoken
	b. 	People speak softly and avoid prolonged eye contact
	c. 	Show respect to elderly and physicians
 	2.	Hispanics tend to be polite and gracious
a. Hispanics part of a rapidly growing population in the United States	
b. Engage in "small talk"
 	3.	African Americans 
	      a. African Americans are often part of a close extended family 
		b. African Americans may use unfamiliar language patterns
	c. Prevent misunderstandings by clarifying what is being said
               4.	Native Americans
	a.	Close family relationships
	b.	Health is state of harmony with nature
	c.	Use of herbs and rituals
 	5.	Many Middle Easterners believe in keeping family affairs within the family
	a. 	History taking may be difficult
	b. 	Health assessment must be done gradually
 	D.	Cross-cultural health beliefs
 	1.	Traditional methods of preventing illness
 		a..	Practices to prevent illness develop from beliefs about the cause
 		b.	  Religious objects are frequently worn to prevent illness
 		c.   Food taboos may be prescribed to prevent illness
 	       2.	Traditional practices to maintain health
 		a.	Wearing proper clothing
 		b.	Eating proper diet
 		c.	Silence, meditation, and prayer 
 		3.	Traditional practices to restore health
 		a.	Use of natural substances to cure illness
 		b.	Try traditional healers before seeking medical help
 		c.	  Ingest a variety of substances 
 		d.	Health care practices, such as dermabrasion or coining
 		4.	Cultural assessment an important skill to develop
 		a.	Plan care that respects cultural differences

 VI. Statistics on Maternal and Infant Health
 	A.	Maternal and infant mortality
 	1.	Reasons for decline in mortality rates
	a. 	Improved sanitation
	b. 	Increase in medical knowledge
	c. 	Antibiotics
	d. 	Public health improvement
	e. 	Increased prenatal care
 	B.	Disparity across racial groups
		1.   Maternal and infant mortality higher for African American women
 	C.	Infant mortality across nations
 	1.	Relatively high rate in the United States (Table 1-3)
 	2.	Major reasons for this high rate
	a. 	Unequal access to health care at all socioeconomic levels
	b. 	Low birth weight and complications of prematurity
        D.  Adolescent pregnancy
              1.	Rates fell in 2002 and are near the Healthy People 2010 target 
	
Teaching/Learning Activities
Theory
 1.	Invite a nurse from the public health department to discuss current infant and maternal morbidity and mortality rates. Compare and discuss the mortality rates among the various cultures in your area (Table 1-3).
 2.	Divide the class into three categories of family structure (mainstream families, nontraditional families, and high-risk families). Compare and contrast the family differences identified within your class.
 3.	Compare the clinical pathway in Figure 1-2 to the guidelines developed in the facility being used for clinical experience.
 4.	Invite students from various cultural groups to share their cultural beliefs about childbearing and parenting. Discuss how these beliefs might create a misunderstanding in a clinical setting where Western beliefs define roles and functions.

Practicum
 1. Visit the local government agencies in your community that provide funding for maternal care and newborn-child care (Table 1-1).
 2. When students are assessing a client and/or family in the clinical area, include assessment of the family structure. Discuss how this structure may influence the family's health care practices.

Extra Credit Activities
1.   Prepare a presentation for your clinical group on how government agencies are funded, what populations they serve, and the nurse's role in client referral.
2.   Compare infant and maternal mortality statistics for your state or county to the national rates in Table 1-3. Discuss reasons why the rates in your area may differ from the national figures.

Critical Thinking Exercises
1.   Some Southeast Asian women do not seek prenatal care because they do not consider pregnancy to be an illness that requires medical care. Develop a teaching plan that respects this cultural belief but would help a woman learn the value of prenatal care.
2.   A pregnant woman in her third trimester is seen in the emergency room for an upper respiratory infection. She tells the nurse who is interviewing her that she plans to deliver her baby at home and does not have an obstetrician. During physical assessment, the nurse finds that the woman has hypertension. What responsibility does the nurse have to initiate further discussion of the woman's plans for her pregnancy and birth?