hello I'm Dr Beth Mueller and this is intro to maternity care it is uh topic 1.1 in nursing 432 in this topic we'll look at planning nursing care for the childbearing family we'll look at uh contemporary issues and Trends and family centered nursing look at kind of the journey over the last couple hundred years examine Health considerations related to the client with female reproductive needs and also evaluate the concepts of contraception and infertility in Family Planning and how that is kind of evolved so when we look at 21st century maternity nursing um that is what this course will cover is childbearing women and their families so we'll look at preconception which is prior to conceiving and conception and then prenatal or antepartum period which is the pregnancy that's approximately 40 weeks I know sometimes we say 9 months but it's essentially like four or excuse me 10 four week months um and then intrapartum which is labor and birth and then postpartum which is birth to six weeks so let's look at some of the advances in care uh over uh the last 150 years or so related to Maternal Child Health so in the early 1900s so over a hundred years ago we started to see more standardized Care for Women in childbirth there were some childbirth classes there was the first milk Bank where they actually kept supply of breast milk prior to this there were things things like wet nurses and things but that was an actual first um formal storage of breast milk and then started to see some improvements in birth control and also feminine products in the mid 1900s there was the introduction of Lama's education which was formal childbirth education finally got the birth control pill um there was uh more research on the causes of birth effects in the uh 1950s and 60s a drug called thalidomide was um WID widely spread use for treatment of morning sickness it was this magic drug that was going to help all these women who were suffering from M morning sickness and uh unfortunately I don't think it had ever even been through the FDA process if it had it wasn't approved but but it was still widely um prescribed and there were like 880,000 babies that were still born or die early um like like a premature birth and then there were of those that actually survived to birth um there were over 20,000 that were born without limbs severe nerve damage it was just massive tragedy and so um they started doing more research on what is safe what during pregnancy what causes birth effects all of those kind of things um and don't get too Caught In The Weeds on a lot of this history I'm just giving you kind of a background on it um also in the mid 1900s naog which is the National Association of American college or excuse me the Nurses Association of American College of obstr OB to Obstetricians and gynecologists so um OBGYNs are usually an AOG and then naog is the Nurses Association branch of that um also in the mid 1900s we started to see um mammograms used to detect early detection of breast cancer late 1900s we finally started to have home pregnancy kits um family medical leave was passed where if some a woman was working and they had a baby they could actually stay home and take care of it and not have to quit their job um also the newborns and mother's health act which um allowed for a minimum of 48 hours after a vaginal birth or 96 hours after a c-section of covered hospital care um also uh and then there was also an introduction of emergency contraception and then in the early 2000s to current days so the last 20 plus years or so um we saw the Affordable Care Act which I'll talk about a little bit more in the in another slide here but um honestly not to tell you how old I am but I was married when my husband was in college and his first job when he graduated was up in the far north of North Dakota and he got a job and had benefits which was uh included health insurance but because I was pregnant when he got that job I could not be covered on his health insurance we had to pay an astronomical amount out of our pocket when he was making like I don't know $6 an hour as a college graduate anyway long long story short sort of um the Affordable Care Act one of the things that um came about from that is that they removed pregnancy as a pre-existing condition for coverage Health Care coverage thank goodness so um also we saw the emergence of the HPV vaccine which helps protect uh against cervical and vaginal cancer and also increasing research on the effects of virus to fetuses and neonates okay uh let's look at some health disparities um our current data shows vulnerable populations such as women racial and ethnic minorities adolescent girls or older women incarcerated women immigrants and refugees homeless and Rural communities all of those um fall into that vulnerable population group whether it be access to Medical Care um access to like um health healthy foods food insecurity all of those things can factor into vulnerable populations and unfortunately there is significant racial disparities as well um my home state of Missouri as of until a month ago when I moved um black women faced a much higher risk of death than non the anyone nonwhite actually faced much greater risks of death um with maternal uh morbidity and mortality and in Missouri it it's very high um and we'll talk about some of the things that might impact that um but honestly over the last uh two decades so the last 20 years the maternal morality rate in the US has has like doubled it's just um very high um and uh the US has the highest maternal mortality rate when compared with any other developed country which is very sad so um there are some efforts to reduce this we have the Hera there's hersa grants which um have health disparity collaboratives where they try to provide care for those who uh do not otherwise have health care coverage there's the office of minority Health which tries to prioritize um those that are experiencing disparities National Institutes of Health there's specific research and education that that is always um continuing on and they have a lot of resource materials as well and then the CDC closely follows the trends of Health disparities and inequities and measures the progress on elimination of those disparities and also HHS the Department of Health and Human Services looks at reducing uh disparities through promoting evidence-based programs um if you've ever heard of the wick program women's infants and children um where they get uh free um healthy foods and education during their pregnancy and and postpartum period and then children up to age five and then also other integrated approaches and best practice to try and reduce the effects of those disparities um another group that if you haven't already heard about it I also teach 310 and I know we talk about healthy people 2030 in there um healthy people 2030 puts out science-based goals every 10 years and the focus is is to improve the health of Americans and they have very specific Maternal Fetal and newborn goals and they include like reducing the rate of fetal and newborn deaths increasing the number of clients who attend childbirth classes because knowledge is power it's important to educate people so they have the autonomy to make informed decisions regarding their health and their pregnancy and their birth process and then always striving to reduce those maternal mortality rates which unfortunately keep Rising there's also Global goals with the UN um focusing on sustainable development goals throughout the world and an overarching elimination of poverty and sustaining the environment um which seems pretty lofty but we we try I uh just want to talk a little bit more about problems with the US Health Care System the structure of delivery uh we have a lot of fragmented care where there's lack of coordination or collaboration among the different Health Care Providers and organizations we are trying to look at reducing those costs where we use manage care and integrated Delivery Systems to kind of help um reduce that fragmented care um but it still may be in may be expensive or really Out Of Reach for many people that they don't have coverage um we also look at reducing medical errors The Institute of medicine does a lot of research on um why an error occurred analyze it develop prevention strategies medical errors are the common major cause of death in the US um and uh that can um raise health care costs if because in Insurance skyrockets because of errors and it's just a big um vicious cycle so when we look at the higher costs of Health Care um higher prices in general um readily accessible technology as technology continues to tra change and grow so do costs um the use of midwives and aprns or nurse practitioners have helped to lower the cost but unfortunately not all insurance companies provide reimbursement for those aprns or nurse practitioners um midwives have significant costs with their insurance and that's why you have some of those small town doctors who used to maybe do a lot more deliveries um and they you know deliver I went to this my mother went to this doctor when she had me and now I go to this doctor with my pregnancy and blah blah blah um if they don't do a lot of deliveries it's very cost prohibitive to keep covering um carrying that um labor and delivery insurance or prenatal the pregnancy Insurance um for providers so um we also have had limited access to care um because people have the inability to pay maybe lack of transportation and dependent child care are barriers if you're in a small town and the two providers that are in that small town have stopped doing labor and delivery then you may have to travel 20 30 minutes or an hour to get to someone who actually does prenatal care and that can be a big burden um also there's a number of providers who maybe refuse to take Medicaid or only have a certain limited number of Medicaid patients they take at any given time um so that is a serious issue as a significant proportion of births are to mothers who receive Medicaid um the health reform I touched on the Affordable Care Act priv previously and patient they kind of combine patient protection and Affordable Care Act um it has allowed Insurance to be a little more accessible and affordable um another benefit of Affordable Care Act was con contraception was included without out of outof pocket cost to the consumer um more preventative services are covered mammograms well women visits with um pap smears um screening for things like diabetes um breast breast feeding equipment and counseling is is now covered and then um again that pregnancy not not being considered a pre-existing condition some uh contemp other contemporary issues and trends when we look at low birth weight and pre-term birth there have been increased risk to morbidity and morality um with infants uh a common indicator of adequacy of prenatal care and the health of the nation in general is included in those infant mortality rates if they are getting higher then um that is a reflection of not not adquate prenatal care and um health problems in general in our nation again disparities um have increased between black infants and non-white infants um higher mortality and morbidity for those um groups and then um we've had uh also birth defects and then um the pre-term and low birth ba weight babies have also in increased with the uh the rates of morbidity and mortality and pregnancy complications SIDS and other uh injuries and then when we look at M maternal mortality Trends um the health disparities have a very strong connection to maternal death um also other health issues hypertensive disorders cardiovascular and non-cardiovascular diseases diabetes infection Hemorrhage and um then when we look specifically at moral morbidity related to um specific factors it could be related to a acute renal failure um and all of these we will talk about in other topics but I'm just touching on them so don't get too In The Weeds on this but amniotic fluid embolism and maybe um other problems with pregnancy like preclampsia clamps um pulmonary embolism there's a number of things that um can contribute to maternal uh morbidity um and then obesity is uh one third uh a little over a third of women in the US um are considered obese which is a BMI over 30 and that can be associated with hypertension or diabetes with pregnancy and it can also impact F fertility con uh congenital anomalies um miscarriage and even fetal death um when we look at birthing practices uh prenatal care the the the when someone has regular prenatal care we we've seen the research there's better pregnancy outcomes there's earlier risk assessment there's promoting of healthy behaviors there's providing that education so people have the autonomy to make those informed decisions regarding their Health and Care um we have Primary Care Providers which may be um MDS OBGYNs MDS like Family Med um certified midwives that makes up a pretty small percentage only about 8% now um they also have doctors of osteopathy or Doos um and then when we look at Birth options people have the option depending on where you live uh maybe to go to a birth center within a hospital there are Standalone birthing centers that provide a little more options and um often have midwives staffed at them and then we've seen arise in home births with either a midwife or a doula at the bedside uh and um Family centered care when we look at this um that is um again often a home birth or sometimes in those Standalone birthing centers they have family centered care where the partners the siblings the extended family everyone that wants to be present is present they can assist with the delivery um there skin to skin immediately after birth is it's strongly encouraged but a lot of in hospitals try to do that as well there's um evidence-based practice that's that uh skin to skin is so um beneficial and then um we uh also see um rooming in for the most part in hospitals and birthing centers where neonates often remain in the room with their parents and may never transfer to the nursery unless there's some medical issue um often they have where you labor and deliver in the same room and then you just stay in that room but not always sometimes you have to move to a different room but anyway um so we do sometimes see early discharge um or because we sometimes have early discharge there may be um home care and there are grants and things that allow for a nurse to come into the home with those um either people who um request it or they feel like maybe um they need some extra support or just anyone that they feel um maybe falls into a category that might be somewhat high risk and it's um allows for for efficient and focused teaching which is very important especially if someone's going home early okay let's look at some Trends in nursing practice um we have standards of practice and legal issues with relation to delivery of care um we've um every every I want to say every week it seems like um we are always looking at ways to prevent errors when those errors occur Joint Commission will go in and investigate as well as Institutes of medicine and that's how why we have a do not use list or lookalike sound alike drugs or whatever it may be um it also uh we have some standards per nurse specialty we have Ana we have A1 um we have acnm Nan all of those don't get too Caught In The Weeds on them it's um Awan is kind of like naog but um it's Association of women's health obstetric n natal nurses um n uh acnm is for nurse midwives a let's see n NN is for neonatal nurses so there's all of those that have Specialties that um also research best practice and spread um in information to those nurse specialties um Sentinel events as we look at Trends uh those are something that results in death or permanent harm or severe temporary harm they're very um acute Adverse Events um that we try to do lots of research um to identify what occurred so that we avoid those in the future um then we have failure to rescue which is just a failure to recognize or act on early signs of distress and in the uh labor and delivery space the inter inter intrapartum space um that is very important we have careful surveillance and identification of complications and then quick appropriate action based on that the team responds based on that and that would be um maternal comp complications like a problem with the placenta placenta abruption um postpartum Hemorrhage after delivery uterine rupture during intrapartum during labor um a number of other things eclampsia amniotic fluid ambul am embolism again don't get too Caught In The Weeds on those we we will discuss all those just be familiar that we have S Sentinel events and then failure to rescue is not ID not recognizing oh here's this fetal heart rate monitor strip and the heart rate the baby's trying to tell us based on the heart rate pattern that it's it's not getting enough um oxygen not enough exchange and we don't act on that so um standards of care for newbor for uh women and newborns it's a little bit different than the typical ad pie we just throw in after assessment and diagnosis we do outcome identification which is just identification of EXP Ed outcomes that are more individualized depending on that person and the state of of the the woman's care or the neonates care and then still the planning implementation and evaluation okay so let's talk a little bit about ethical issues in perinatal nursing and Women's healthc Care we have had so many technology and scientific advances even in the last 25 years so um and that um includes Advanced fertility treatments um chronic disease or illness and still able to carry a pregnancy um your book presents a number of ethical issue questions like should scarce resources be devoted to achieving pregnancies in older women is giving birth to a child at an old older age worth the risks should older parents be encouraged to conceive a baby when they may not live to see the child reach to adulthood honestly um there are a number of ethical issues that get presented as as we um get more technologically advanced and able to do things um ever since the first test Tu baby it has just grown and and progressed so um those aren't anything we're going to solve or discuss even in this course so um we just want you to be aware that there are ethical issues as technology advances also we do have something called um uh age of viability meaning the age that we do some sort of life-saving measures on um a neonate or uh a fetus if and So currently that age of viability is 20 weeks so if a woman is 19 and 27 weeks and starts to go into labor chances are they will probably not do anything to stop that because that child and its chances to survive are very slim because they've determined that the current age of viability is 20 20 weeks so don't get too Caught In The Weeds on that either that is a discussion for another chapter but I just wanted you to be aware of as we progress with um honestly when I was first a nurse um the age of viability uh when I was first in OB was like 25 weeks and so someone um prematurely delivered 23 week twins we weren't allowed to do much for them other than keep them warm we weren't allowed to do Li saving measures which haunts my dreams now but that's how it was back then so anyway all of those Trends as things change they become more ethical discussions um it is important that we provide informed consent meaning that we provide education regarding options and allocation of resources and availability of resources and um whether that be um preconception during concept this conception process prenatal care labor delivery all of those things we need to make sure that we provide um we as Health Care Professionals and the providers we all pro that the patient receives the important informed consent and information to make autonomous decisions so uh the family culture and Home Care um the family organization and structure um typically say um 50 or 100 years ago it was a nuclear traditional family with a husband wife and children that is steadily decreasing we now see more multi-generational families um nonbiologic parent families married Blended cohabitating parent single parent lgbtqia families all of those have um changed in what we picture now as a as family that that traditional nuclear family now looks a lot differently than the way it did um in previous decades or centuries so when we look at theoretical approaches to understanding families and how families present themselves now the the perinatal nurse um or the Maternal Child health nurse um applies health promotion rather than an illness care model we aren't doing that reactionary illness care we are promoting Health we're giving it education we're talking about pre preconception care and the importance of of a healthy pregnancy and a healthy labor and delivery and all of those things we look at the structural Developmental and functional aspects of the family the interaction of the individuals within the family who makes up that family who needs to be included in um education in um teaching all of that the lowrisk family we try to promote healthy birth outcomes so we have lower risks and then um with high risk families we identify those risks and um see if there are preventative measur measures and also any illness care needs that those families may have okay one thing I didn't really touch on when I was talking about technology advances um when we look at theoretical approaches to understanding families we now have genetic um research we have things um that we are able to do um that we can go more in depth into families and things that may affect health and so this first image here uh is from your book it is the family genogram and it depicts a family history so um they're able to look at the the parents and um their children and any health issues they have it goes into a little more detail um it me it shows that the grandfather had a heart attack um uh this this person this sibling healthy or whatever it may be it goes into more detail looking at connections were they're multiples were they're twins were they triplets um was what did the family situation look like how did it evolve were they married and then divorced all of that goes into a family genogram and then that EO Echo map um it just describes the social relationships and um looks at available support so if you are a perinatal nurse and maybe you have someone who's in pre-term labor and they need you need to identify now who in this family if this patient goes home and is on bed rest who's available what does that look like as far as their social environment and any support systems that's where that might get used and then uh just real quick to touch on the family in a cultural context this be much more um inde depth as you get toward the end of this course and you do um a cultural presentation uh on your assigned culture uh so we want to always make sure uh with childbearing beliefs and practices that we're um providing culturally competent care respectful care considering all aspects of culture that would go into our culture including communication um space and time orientation family roles um how do you communicate with your client do you need interpreters do you need translators that provide um appropriate written education materials and then looking at personal space being aware of varied degrees of space some people want you right there other people need you at an arms length and lack of awareness can heighten someone's sociiety if you are if someone has a very broad area of space bubble and you're in their space bu bubble trying to help them labor breathe or whatever that can heighten someone's anxiety so it's personal space also needs to be Contin considered time orientation orientation to pass present future that can greatly vary by culture and it may be focused on dayto day survival if you have someone who's homeless or um maybe doesn't have access to care for medical uh uh monetary reasons or whatever that may be their time orientation it may be just getting by whatever they have to do to get through the day so all of that um the perinatal nurse needs to be aware of and then again family roles what are the positions in the larger family are there um any family roles that are affected by someone's social class or their cultural norms okay that was a pretty brief overview of an introduction to maternity nursing uh a lot of those topics we will go into more uh indepth discussion as you progress through this course but always if you have questions please reach out to your cour and uh professor