A GLIMPSE AT MATERNITY NURSING in the 21 st CENTURY K. L. Ringgenberg, RNC, MSN, WHNP Shanghai Jiao Tong University SON April 5, 2006.

A GLIMPSE AT MATERNITY NURSING in the 21st CENTURY

K. L. Ringgenberg, RNC, MSN, WHNPShanghai Jiao Tong University SONApril 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

• 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?