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Improving Access to Maternity
Care
21st Century Maternity Nursing
Maternal Medical Risk Factors
The most frequently reported maternal medical risk factors are diabetes mellitus and chronic hypertension, often associated with maternal obesity. Other notable maternal medical risk factors include mitral valve prolapse and anemia, though these are not as commonly reported as diabetes and hypertension.
Communication and Teamwork
Effective communication among healthcare providers is crucial to ensure optimal patient outcomes. The SBAR (Situation, Background, Assessment, Recommendation) technique is an easy-to-remember framework for communication. The contemporary maternity nurse must incorporate both teamwork and communication with clinicians into her care delivery.
Evolved Role of the Maternity Nurse
The role of the professional nurse caring for childbearing families has evolved to emphasize an evidence-based approach to practice. Nurses are part of the collaborative team of healthcare providers caring for patients throughout the childbearing cycle, providing care in various settings beyond just the hospital. Nurses have been instrumental in developing strategies to improve the well-being of women and infants, and have led efforts to implement clinical practice guidelines using an evidence-based approach.
Barriers to Prenatal Care Access
The most significant barrier to access to prenatal care is the pregnant woman's inability to pay for services, which is compounded by the fact that many physicians refuse to care for women who cannot pay. Other barriers, such as age, minority status, and educational level, are also associated with disparities in morbidity and mortality rates, but are not the most significant barriers to access of care.
Nursing's Role in Research
The primary role of practicing nurses in the research process is to identify researchable problems, as this leads to the development of evidence-based practice guidelines. Nurses are responsible for following agency policies and procedures, which should reflect current standards of care, when performing patient care procedures.
Reducing Infant Mortality
The focus of the healthcare system to further reduce the rate of infant mortality should be on implementing programs to ensure women's early participation in ongoing prenatal care, as this allows for early diagnosis and appropriate interventions. Increasing the length of hospital stay, expanding neonatal intensive care units, or mandating obstetric care for all pregnant women are not the primary measures that should be the focus for further reducing infant mortality rates.
Alternative and Complementary Therapies
Alternative and complementary therapies recognize the value of the client's input into their healthcare and focus on the whole person, not just the disease they are experiencing. These therapies are used by a significant number of American adults, and are not intended to replace conventional Western modalities of treatment, but rather to be used in conjunction with them.
Integrative Health Care and Alternative
Healing Modalities
Alternative and Complementary Therapies
Many popular alternative healing modalities offer human-centered care based on philosophies that recognize the value of the patients' input and honor the individuals' beliefs, values, and desires. Alternative and complementary therapies are part of an integrative approach to health care. An increasing number of American adults are seeking alternative and complementary health care options. Alternative healing modalities offer a holistic approach to health, focusing on the whole person, not just the disease.
Integrative Health Care
Integrative health care tries to blend complementary and alternative therapies with conventional Western treatment. Integrative health care focuses on the whole person, not just the disease or condition.
Midwifery Care
Midwifery services are available to all low-risk pregnant women, regardless of the type of insurance they have. Midwifery care in all developed countries is strictly regulated by a governing body, which ensures that core competencies are met. Midwives can provide care and delivery at home, in freestanding birth centers, and in community and teaching hospitals.
Female Genital Mutilation (FGM)
With the growing number of immigrants from countries where FGM is practiced, nurses will increasingly encounter women who have undergone the procedure. The extent of the client's circumcision will affect the potential for complications, such as pain, bleeding, scarring, or infection. The client may require surgery before childbirth.
Medication Safety
The abbreviations i.u. and I.U. are no longer acceptable because they could be misread as I.V. or the number 10. Abbreviations like q.o.d. or Q.O.D. should be written out as "every other day" to avoid confusion. Medications like MSO4 or MgSO4 should be written as morphine sulfate and magnesium sulfate to avoid confusion. The decimal point should never be missed before a number to avoid confusion (i.e., 0.4 rather than .4).
Maternal-Child Health Priorities and Nursing
Roles
Healthy People 2020 Priorities
Healthy People 2020 has established national health priorities that focus on a number of maternal-child health indicators. Significant progress has been made in: a. The reduction of fetal deaths and increased use of prenatal care. b. Reducing low birth weight and preterm birth. c. Eliminating health disparities based on race. d. Reducing infant mortality and preventing birth defects.
Trends in Maternal-Child Health
Trends in maternal-child health indicate progress has been made in reducing infant and fetal deaths and increasing prenatal care utilization. Notable gaps remain in the rates of low birth weight and preterm births.
Persistent disparities still exist between African Americans and non- Hispanic Caucasians in these negative outcomes. Many of these negative outcomes are preventable through access to prenatal care and the use of preventive health practices. This demonstrates the need for comprehensive community-based care for all mothers, infants, and families.
Nursing Roles
Nurses are assuming greater roles in assessing family health and providing care across the perinatal continuum. It is important for nurses to be aware of the progress made and the remaining challenges in maternal-child health.
Interventions to Improve Access to Maternity
Care
Providing transportation to prenatal visits can help alleviate access barriers. Providing childcare so that pregnant women can attend prenatal visits is another important intervention. Providing low-cost or no-cost health care insurance is crucial to improving access to maternity care. House calls and job training are not effective interventions for improving access to maternity care.
Family-Centered Care Techniques
Allowing the partner time to ask questions and enabling the mother and father to make choices when possible are important elements of family- centered care. The nurse should never command the mother to do as she is told. Family-centered care involves collaboration between the health care team and the client. Unless an institutional policy limits the number of attendants, the client should be allowed to have whomever she wants present during delivery.
Safe Nursing Practices
The National Quality Forum has recommended numerous safe practices that nursing can promote to reduce medical errors: Ask the patient to teach back information Comply with CDC guidelines Ensure information is documented in a timely manner Promote interventions to reduce patient risk Reduce exposure to radiation
Nuclear Family
Male and female partners and their children live as an independent unit. About two thirds of U.S. households meet the definition of a nuclear family.
Family Systems Theory
A family system is part of a larger suprasystem. A change in one family member affects all family members. The family is able to create a balance between change and stability.
Assessing Family Structure and Culture
Genogram
A pictorial tool that can assist the nurse in assessing aspects of family life related to health care. Depicts the relationships of family members over generations.
Acculturation
The process by which people retain some of their own culture while adopting the practices of the dominant society. This process takes place over the course of generations.
Communicating with Patients of Different Cultures
Providing privacy creates an atmosphere of respect and puts the patient at ease. The nurse should not rush to judgment and should make sure that he or she understands the patient's message clearly. In crisis situations, the nurse may need to use a family member or neighbor as a translator. The nurse should talk directly to the patient to create an atmosphere of respect.
Cultural Differences in Paternal Involvement
European-Americans expect the father to take a more active role in the labor and delivery than the other cultures.
Cultural Competence in Nursing
Local health care workers and community advocates can help extend health care to underserved populations. Nurses must develop an awareness of and sensitivity to various cultures.
A culture's economic, religious, and political structures influence practices that affect childbearing. The cultural context of the nurse also affects nursing care.
Nurse Safety During Home Visits
Nurses should visit in pairs, have access to a cell phone at all times, and wear a limited amount of jewelry. The car should be parked in a well-lit area and locked at all times. An extra set of keys kept in the nursing home care bag avoids time and frustration if the nurse should become locked out of her automobile. Groups of strangers, dark alleys, and unrestrained dogs should be avoided at all times.
Working with Interpreters
Outline your statements and questions, listing the key pieces of information you need to know. Learn something about the culture of the patient. Make sure the interpreter is comfortable with technical terms. Introduce yourself to the interpreter and converse informally. Stop every now and then and ask the interpreter "How is it going?" Make notes on what you learned for future reference.
Assessment and Health Promotion
Ovarian Functions
The two primary functions of the ovary are: Ovulation and hormone production. The ovaries produce estrogen, progesterone, and androgen hormones. Ovulation is the release of a mature ovum from the ovary.
Uterine Functions
The uterus is a muscular, pear-shaped organ responsible for: Cyclic menstruation.
The uterus is an organ for reception, implantation, retention, and nutrition of the fertilized ovum.
The unique muscle fibers of the uterine myometrium make it ideally suited for:
The birth process. The myometrium's smooth muscle layers assist in expelling the fetus, ligating blood vessels after birth, and controlling the opening of the cervical os.
Eating Disorders
The long-term treatment plan for an adolescent with an eating disorder focuses on: Restructuring perception of body image. The primary focus of therapy for eating disorders is to help the adolescent cope with complex issues and restructure cognitive perceptions about their body image.
Cultural Considerations
The most appropriate response from the nurse when a woman states she has special undergarments she does not remove for religious reasons would be:
Tell me about your undergarments. I'll explain the examination procedure, and then we can discuss how you can have your examination comfortably. The nurse must respect the rich and unique qualities that cultural diversity brings to individuals and modify the plan of care to meet the needs of each woman.
To facilitate a positive health care experience for a 62-year-old woman who has not been to the clinic for 5 years, the nurse should:
Listen carefully and allow extra time for this woman's health history interview. A respectful and reassuring approach to caring for women older than age 50 can help ensure they continue to seek health care.
Pelvic Examination
The correct response when a woman states she thinks she has bumps on her labia would be to:
Explain the process of vulvar self-examination to the woman and reassure her that she should become familiar with normal and abnormal findings during the examination. Providing this education empowers the woman and emphasizes her role in self-care and health promotion.
The nurse's initial response when a woman arrives for her annual examination and says she has been using an over-the-counter cream for a suspected vaginal infection should be to:
Ask the woman to describe the symptoms that indicate to her that she has a vaginal infection. Obtaining the woman's symptom description is an important element of the history and physical examination.
Menopause
The transition phase during which ovarian function and hormone production decline is called: The climacteric. The climacteric is the transitional phase during which ovarian function and hormone production decline.
Breast Self-Examination
A statement that would indicate the client requires additional instruction about breast self-examination is: Yellow discharge from my nipple is normal if I'm having my period. Discharge from the nipples requires further examination from a health care provider.
Breast Self-Examination and Intimate Partner
Violence
Breast Self-Examination
Women should check their breasts at the same time each month, such as after their period, to perform a breast self-examination. During the examination, women should feel in the armpit area as well as check each breast in a circular motion. This routine helps ensure successful learning and early detection of any abnormal changes in the breasts.
Intimate Partner Violence (IPV)
A woman who is 6 months pregnant has sought medical attention after falling down the stairs. Indicators that may suggest the woman is a victim of IPV include: The woman and her partner are having a loud and hostile argument. The woman has injuries in various stages of healing on different parts of her body, indicating a pattern of violence. Examination reveals a fractured arm and fresh bruises, which could be caused by the reported fall but may also indicate IPV. The woman avoids eye contact and is hesitant to answer questions.
Breast Lump Evaluation
When a 20-year-old patient calls the clinic to report finding a lump in her breast, the nurse's best response is to: Acknowledge the patient's concern but reassure her that many women have benign lumps and bumps in their breasts. Recommend the patient come in for a thorough examination by a physician to ensure the lump is benign. Avoid discrediting the patient's findings, as this may discourage her from continuing breast self-examinations.
Regular Pap tests should be performed, depending on the patient's age, as part of the adult physical examination.
Adolescent Breast Development
During adolescence, one breast may grow faster than the other, which can cause stress and self-consciousness for the young woman. The nurse should provide education about normal breast development and encourage the patient to begin regular breast self-examinations.
Reproductive System Concerns
Amenorrhea
Amenorrhea is the absence of menstrual periods. It is unlikely to be caused by lack of exercise, as strenuous exercise may actually cause amenorrhea. Possible causes of amenorrhea include: Anatomic abnormalities Type 1 diabetes mellitus Hysterectomy
Primary Dysmenorrhea
Primary dysmenorrhea is menstrual pain or cramps that are not associated with any underlying condition. Nonpharmacologic interventions that may help relieve primary dysmenorrhea include: Using a heating pad on the abdomen to increase vasodilation and muscle relaxation Other recommendations may include: Reducing intake of diuretic foods Increasing physical activity
Premenstrual Syndrome (PMS)
PMS is a cluster of physical, psychological, and behavioral symptoms that begin in the luteal phase of the menstrual cycle and resolve within a couple of days of the onset of menses. A characteristic symptom of PMS is feeling irritable and moody a week before the period is supposed to start.
Endometriosis
Endometriosis is a condition where the endometrial tissue grows outside the uterus, causing severe abdominal and pelvic pain, especially around the time of menstruation. Other symptoms of endometriosis include deep pelvic pain during intercourse and infertility.
Nafarelin Treatment for Endometriosis
Nafarelin is a GnRH agonist used to treat mild-to-severe endometriosis. Side effects of nafarelin include hot flashes and vaginal dryness, similar to menopausal effects. Nafarelin is administered as a nasal spray, twice daily.
Menstrual Cycle Variations
Variations in the length of a menstrual cycle, from 26 to 29 days, are considered normal. Menorrhagia, or excessive menstrual bleeding in duration or amount, should be further evaluated. Spotting or light bleeding midway between periods (mittelschmerz) is a normal finding.
Amenorrhea and Menstrual Disorders
Amenorrhea
Amenorrhea, or the absence of menstrual flow, is most often a result of pregnancy. Other contributing factors include stress, excessive exercise, and eating disorders, but these are not the most common causes of amenorrhea.
Uterine Fibroids
Uterine fibroids are benign tumors of the smooth muscle of the uterus. Their etiology is unknown, but they are estrogen-sensitive and shrink as estrogen levels decline. Fibroids occur in 25% of women of reproductive age and are seen in 2% of pregnant women. The major symptoms associated with fibroids are menorrhagia (excessive menstrual bleeding) and the physical effects produced by large myomas.
Dysmenorrhea
Dysmenorrhea is pain during or shortly before menstruation. It is more common in women aged 17 to 24 years, women who smoke, and women who are obese. Symptoms begin with menstruation or sometimes a few hours before the onset of flow. Pain is described as sharp and cramping or sometimes as a dull ache, usually occurring in the suprapubic area or lower abdomen.
The most prevalent viral STI is human papillomavirus (HPV) infection.
Treatment of STIs
The CDC recommends that HPV be treated with client-applied topical podofilox 0.5% solution or gel. Fluconazole is the drug of choice to treat candidiasis, a fungal STI.
HIV Testing
Most laboratory tests for HIV focus on detecting HIV antibodies, as this is the screening tool used to detect the virus.
Pelvic Inflammatory Disease (PID)
Care management of acute PID most likely would include bed rest in a semi-Fowler position. Broad-spectrum antibiotics are used, and the regimen must be continued until symptoms subside.
Bacterial Vaginosis
Bacterial vaginosis is characterized by a profuse, thin, grayish-white vaginal discharge with a fishy odor and mild irritation or pruritus.
Prevention of HIV Transmission During Pregnancy
The recommended treatment for the prevention of HIV transmission to the fetus during pregnancy is zidovudine.
Perinatal Transmission of HIV and Sexually
Transmitted Infections
Perinatal Transmission of HIV
Perinatal transmission of HIV has decreased significantly in the past decade as a result of prophylactic administration of the antiretroviral drug zidovudine to pregnant women in the prenatal and perinatal periods.
Antiviral and Antibacterial Treatments
Acyclovir is an antiviral treatment for HSV. Ofloxacin is an antibacterial treatment for gonorrhea. Podophyllin is a solution used in the treatment of human papillomavirus.
Characteristics of Sexually Transmitted Infections
Herpes Simplex Virus (HSV)-
The initial HSV genital infection is characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria, which may last 2 to 3 weeks. Recurrent episodes of HSV infection commonly have only local symptoms that usually are less severe than the symptoms of the initial infection.
Human Papillomavirus (HPV)
With HPV infection, lesions are a chronic problem.
Human Immunodeficiency Virus (HIV)
Seroconversion to HIV positivity usually occurs within 6 to 12 weeks after the virus has entered the body. Severe depression of the cellular immune system associated with HIV infection characterizes acquired immunodeficiency syndrome (AIDS), which has no cure.
Cytomegalovirus (CMV)
In most adults, the onset of CMV infection is uncertain and asymptomatic, but the disease may become a chronic, persistent infection.
Counseling on Safe Sex Practices
An essential component of counseling women regarding safe sex practices includes discussion on avoiding the exchange of body fluids. The physical barrier promoted for the prevention of sexually transmitted infections and HIV is the condom. Nurses can help motivate clients to use condoms by initiating a discussion related to strategies to enhance condom use.
Breast Cancer
Risk Factors
Risk factors identify less than 30% of women in whom breast cancer eventually will develop. The exact cause of breast cancer is unknown.
Sexually Transmitted Infections (STIs)
Chlamydia
Chlamydia is a sexually transmitted infection that can be successfully treated and cured. The usual treatment is doxycycline or azithromycin, and concurrent treatment of all sexual partners is needed to prevent recurrence.
Other STIs
Herpes has no known cure, and treatment focuses on pain relief and preventing secondary infections. There is no known cure for AIDS, so prevention and early detection are the primary focus of care management. Condylomata acuminata (venereal warts) are caused by human papillomavirus, and no treatment eradicates the virus.
Benign Breast Conditions
Ductal Ectasia
Ductal ectasia is a benign breast condition that results in a firm, irregular mass in the breast, enlarged axillary nodes, and nipple discharge. It generally occurs in women approaching menopause.
Intraductal Papilloma
Intraductal papillomas develop in the epithelium of the ducts of the breasts, and as the mass grows, it causes trauma or erosion within the ducts.
Chronic Cystic Disease
Chronic cystic disease causes pain and tenderness in the breast.
Fibroadenoma
Fibroadenoma is evidenced by fibrous and glandular tissues in the breast. It is most common in the teenage years.
Gonorrhea Treatment
The drug of choice for the treatment of gonorrhea is ceftriaxone. Penicillin is used to treat syphilis, tetracycline is prescribed for chlamydial infections, and acyclovir is used to treat herpes genitalis.
Fibrocystic Changes
Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderness. The pain and tenderness fluctuate with the menstrual cycle. Fibrocystic changes are not premalignant changes.
Self-Help Modalities for Premenstrual
Dysphoric Disorder (PMDD)
Effective self-help modalities for PMDD include: Regular exercise Improved nutrition Smoking cessation Use of oil of evening primrose
Sexual Risk Behaviors for STIs
Examples of sexual risk behaviors associated with exposure to an STI include: Fellatio Unprotected anal intercourse Multiple sex partners
Breast Cancer Risk Factors
Common risk factors for breast cancer include: Family history Race Nulliparity or first pregnancy after age 30
Herbal Preparations for Menstrual Problems
Herbal preparations with the following actions may be used for the management of menstrual problems: Fennel and dong quai: Uterotonic Chaste tree fruit: Decreases prolactin levels Black cohosh: Estrogen-like luteinizing hormone suppressant Valerian and wild yam: Uterine antispasmodic and anti-inflammatory
Infertility and Conception Control
Infertility
Infertility is perceived differently by women and men, with women tending to be more stressed about infertility tests and placing more importance on having children.
