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A GLIMPSE AT MATERNITY NURSING in the 21st CENTURY
K. L. Ringgenberg, RNC, MSN, WHNPShanghai Jiao Tong University SONApril 5, 2006
“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)
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
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)
Intrapartum Care in the 21st Century
• Care provided during the birth process
• Vaginal Delivery• Cesarean Section
Cesarean Sections
• 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
Settings
• Home• Birthing Centers• Hospitals-Labor, Delivery &
Recovery Rooms (LDR), LDRP (post-partum), Single room maternity care, Birthing rooms
Latest Technologies
• Electronic Fetal Monitoring (EFM)• Ultrasonography• Infusion pumps• Electronic monitoring devices: 1. Non-invasive 2. Invasive
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
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
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
Critically Ill OB
• Continuous cardiac monitoring• Invasive hemodynamic
monitoring• CVP• Arterial lines• Pulmonary artery lines• Ventilator
Genetics
• Human Genome Project• Relationship to Maternity Nursing• Advanced maternal age• Patterns of inheritance• Prenatal testing• Genetic counseling• Ethics and other
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