The Past, Present, and Future

Obstetrics

The skill and knowledge related to obstetrics have evolved over centuries. The earliest records concerning childbirth are in the Egyptian papyruses (circa 1550 bc). Later advances were made by Soranus, a Greek physician who practiced in second-century Rome and who is known as the father of obstetrics. He instituted the practice of podalic version, a procedure used to rotate a fetus to a breech, or feet-first, position. Podalic version is important in the vaginal delivery of the second infant in a set of twins. In this procedure the physician reaches into the uterus and grasps one or both of the infant’s feet to facilitate delivery. Planned cesarean birth is safer than podalic version and today is used more often.

With the decline of the Roman Empire and the ensuing Dark Ages, scientific exploration and associated medical improvements came to a halt. During the nineteenth century, however, Karl Credé (1819-1892) and Ignaz Semmelweis (1818-1865) made contributions that improved the safety and the health of mother and child during and after childbirth. In 1884 Credé recommended instilling 2% silver nitrate into the eyes of newborns to prevent blindness caused by gonorrhea. Credé’s innovation has saved the eyesight of incalculable numbers of babies.

Semmelweis’s story is a classic in the history of maternity care. In the 1840s he worked as an assistant professor in the maternity ward of the Vienna general hospital. There he discovered a relationship between the incidence of puerperal fever (or “childbed fever”), which caused many deaths among women in lying-in wards, and the examination of new mothers by student doctors who had just returned from dissecting cadavers. Semmelweis deduced that puerperal fever was septic, contagious, and transmitted by the unwashed hands of physicians and medical students. Semmelweis’s outstanding work, written in 1861, is titled The Causes, Understanding, and Prevention of Childbed Fever. Tragically, not until 1890 was his teaching finally accepted.

Louis Pasteur (1822-1895), a French chemist, confirmed that puerperal fever was caused by bacteria and could be spread by improper handwashing and contact with contaminated objects. The simple, but highly effective, procedure of handwashing continues to be one of the most important means of preventing the spread of infection in the hospital and the home today.

Joseph Lister (1827-1912), a British surgeon influenced by Pasteur, experimented with chemical means of preventing infection. He revolutionized surgical practice by introducing antiseptic surgery.

Pediatrics

Methods of child care have varied throughout history. The culture of a society has a strong influence on standards of child care. Many primitive tribes were nomads. Strong children survived, whereas the weak were left to die. This practice of infanticide (French and Latin infans, “infant,” and caedere, “to kill”) helped to ensure the safety of the group. As tribes became settled, more attention was given to children, but they were still frequently valued only for their productivity. Certain peoples, such as the Egyptians and the Greeks, were advanced in their attitudes. The Greek physician Hippocrates (460-370 bc) wrote of illnesses peculiar to children.

In the Middle Ages, the concept of childhood did not exist. Infancy lasted until about age 7 years, at which time the child was assimilated into the adult world. The art of that time depicts children wearing adult clothes and wigs. Most children did not attend school.

Christianity had a considerable impact on child care. In the early seventeenth century, several children’s asylums were founded by Saint Vincent de Paul. Many of these eventually became hospitals, although their original concern was for the abandoned. The first children’s hospital was founded in Paris in 1802. In the United States, numerous homeless children were cared for by the Children’s Aid Society, founded in New York City in 1853. In 1855 the first pediatric hospital in the United States, The Children’s Hospital of Philadelphia, was founded.

Abraham Jacobi (1830-1919) is known as the father of pediatrics because of his many contributions to the field. The establishment of pediatric nursing as a specialty paralleled that of departments of pediatrics in medical schools, the founding of children’s hospitals, and the development of separate units for children in foundling homes and general hospitals. By the 1960s, separate pediatric units were also common in hospitals. Parents were restricted by rigid visiting hours that allowed parent-infant contact for only a few hours each day; when medically indicated, nursing mothers were allowed to enter the pediatric unit for 1 hour at a time to breastfeed their infants.

Obstetric and Pediatric Care in the United States

The immigrants who reached the shores of North America brought with them a wide variety of practices and beliefs about the birth process. Many practices were also contributed by the Native American nations. Most deliveries in the early United States were attended by a midwife or relative. One physician, Samuel Bard, who was educated outside the United States, is credited with writing the first American textbook for midwives in 1807.

As a young Harvard physician, Oliver Wendell Holmes (1809-1894) wrote a paper detailing the contagious nature of puerperal fever but he, like Semmelweis, was widely criticized by his colleagues. Eventually, the “germ theory” became accepted, and more mothers and babies began to survive childbirth in the hospital.

Before the 1900s most babies were born at home. Only very ill patients were cared for in lying-in hospitals. Maternal and child morbidity and mortality were high in such institutions because of crowded conditions and unskilled nursing care. Hospitals began to develop training programs for nurses. As the medical profession grew, physicians developed a closer relationship with hospitals. This, along with the advent of obstetric instruments and anesthesia, caused a shift to hospital care during childbirth. By the 1950s, hospital practice in obstetrics was well-established. By 1960, more than 90% of births in the United States occurred in hospitals.

However, hospital care during that time did not embrace the family-centered approach. Often the father waited in a separate room during the labor and birth of his child. The mother was often sedated with “twilight sleep” and participated little during labor and delivery. After birth the infant was not reunited with the parents for several hours, which resulted in a delay of parent-infant bonding.

Organizations concerned with setting standards for maternity and pediatric nursing developed. These included the American College of Nurse-Midwives (ACNM); the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), which was formerly the Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG); and the Division of Maternal Nursing within the American Nurses Association (ANA). The American Academy of Pediatrics (AAP), made up of pediatricians from across the nation, has established a position of leadership in setting health standards for children.

Family-Centered Care

In family-centered childbearing, the family is recognized as a unique system. Every family member is affected by the birth of a child; therefore, family involvement during pregnancy and birth is seen as constructive and, indeed, necessary for bonding and support. To accommodate family needs, alternative birth centers, birthing rooms, rooming-in units, and mother-infant coupling have been developed. These arrangements are alternatives to the previous standard of separate areas for labor and delivery, which made it necessary to transport a mother from one area to another and fragmented her care.

The three separate sections of the maternity unit—labor-delivery, postpartum, and newborn nursery—have merged. The whole sequence of events may take place in one suite of labor, delivery, and recovery (LDR) rooms. The patient is not moved from one area to another, but receives care during labor and delivery and then remains in the same room to recover and care for her new infant. The rooms are often decorated to look homelike.

Freestanding birthing centers outside the traditional hospital setting are popular with low-risk maternity patients. These birthing centers provide comprehensive care, including antepartum, labor-delivery, postpartum, mothers’ classes, lactation classes, and follow-up family planning. Home birth using midwives is not a current widespread practice, because malpractice insurance is expensive and emergency equipment for unexpected complications is not available.

Financial Considerations

Cost containment is the efficient and effective use of resources. It includes monitoring and regulating expenditures of funds and involves the institution’s budget. At first, cost containment influenced maternity care by requiring the discharge of mother and newborn in 24 hours or less after delivery. As a result of problems that occurred, current legislation allows a 48-hour hospital stay for vaginal deliveries and a stay of 4 days for a cesarean section.

Changing Perceptions of Childbearing

Current maternity practice focuses on a high-quality family experience. Childbearing is seen as a normal and healthy event. Parents are prepared for the changes that take place during pregnancy, labor, and delivery. They are also prepared for the changes in family dynamics after the birth. Treating each family according to its individual needs is considered paramount.

During the 1950s, the hospital stay for labor and delivery was 1 week. The current average stay in uncomplicated cases is 2 days. Routine follow-up of the newborn takes place within 2 weeks. A nurse visits the homes of infants and mothers who appear to be at high risk.

Midwives

Throughout history, women have played an important role as birth attendants or midwives. The first school of nurse-midwifery opened in New York City in 1932. There are many accredited programs across the United States, all located in or affiliated with institutions of higher learning. The certified nurse-midwife (CNM) is a registered nurse who has graduated from an accredited midwife program and is nationally certified by the American College of Nurse-Midwives. The CNM provides comprehensive prenatal and postnatal care and attends uncomplicated deliveries. The CNM ensures that each patient has a backup physician who will assume her care should a problem occur.

Role of the Consumer

Consumerism has played an important part in family-centered childbirth. In the early 1960s, the natural childbirth movement awakened expectant parents to the need for education and involvement. Prepared childbirth, La Leche League (breastfeeding advocates), and Lamaze classes gradually became accepted. Parents began to question the routine use of anesthesia and the exclusion of fathers from the delivery experience.

Today, a father’s attendance at birth is common. Visiting hours are liberal, and extended contact with the newborn is encouraged. The consumer continues to be an important instigator of change. Consumer groups, with the growing support of professionals, have helped to revise restrictive policies once thought necessary for safety. It has been demonstrated that informed parents can make wise decisions about their own care during this period if they are adequately educated and given professional support.

Cultural Considerations

Culture is a body of socially inherited characteristics that one generation hands down to the next. Culture consists of values, beliefs, and practices shared by members of the group. Culture becomes a patterned expression of the thoughts and actions (called traditions) and affects the way patients respond to health care.

The United States is a culturally diverse nation, and nurses must develop cultural awareness and cultural sensitivity to practices and values that differ from their own. Only this way nurses can develop the cultural competence that will enable them to adapt health care practices to meet the needs of patients from various cultures.

The cultural background of the expectant family strongly influences its adaptation to the birth experience. Nursing Care Plan 1-1 lists nursing interventions for selected diagnoses that pertain to cultural diversity. One way in which the nurse gains important information about an individual’s culture is to ask the pregnant woman what she considers normal practice. Data collection questions might include the following:

Such information helps to promote understanding and individualizes patient care. It also increases the satisfaction of the patient and the nurse regarding the quality of care provided. Cultural influences on nursing care are discussed in Chapter 6.

Technology and Specialty Expertise

Technological advances have enabled many infants to survive who might otherwise have died (Figure 1-1). High-risk prenatal clinics and the neonatal intensive care unit offer the 1-lb preemie an opportunity to survive. Children with heart problems are now treated by a pediatric cardiologist. Much of the complex surgery needed by the newborn with a congenital defect is provided by the pediatric surgeon. Emotional problems are managed by pediatric psychiatrists. Many hospital laboratories are well equipped to test pediatric specimens. Chromosomal studies and biochemical screening have made identification of risks and family counseling more significant than ever. The field of perinatal biology has advanced to the forefront of pediatric medicine.

The medical profession and allied health agencies work as a team to ensure the total well-being of the patient. Children with defects previously thought to be incompatible with life are taken to special diagnostic and treatment centers where they receive expert attention and care. After discharge, many of these children are being cared for in their homes. The number of chronically disabled children is growing. Some are dependent on sophisticated hospital equipment such as ventilators and home monitors. The required nursing care at home may call for the suctioning of a tracheostomy, central line care, and other highly technical skills. Parents must be carefully educated and continually supported. Although this type of care is cost-effective and psychologically sound for the child, respite care is extremely important, because 24-hour-a-day care is extremely taxing for the family, both physically and psychologically.

Genomics

Genomics is the study of the functions of all of the genes in the human body, with a focus on their interactions with each other and the environment. The Human Genome Project has identified all genetic material present in the human body. The door is now open for medical researchers to identify genes responsible for specific congenital disorders and develop “gene therapy” to replace missing genes or alter defective genes (Figure 1-2). This knowledge, combined with technological advances, can result in earlier diagnosis, earlier intervention, and an integration of genomic knowledge in patient education as well as therapy.

Health Care Delivery Systems

Cost containment is a major motivating factor in current health care, especially when health costs rise without decreases in morbidity and mortality. Many hospitals are merging to increase their buying power and reduce duplication of services.

Insurance reimbursement has become an important consideration in health care. The federal government has had to revise its Medicare and Medicaid programs. Among other changes, it instituted diagnosis-related groups (DRGs). These refer to a Medicare system that determines payment for a hospital stay based on the patient’s diagnosis. This mandate has had a tremendous impact on health care delivery. Patients are being discharged earlier from the hospital, and more care is being given in skilled nursing facilities and in the home. Some insurance companies are employing nurses in the role of case managers. Nurses remaining in institutions also may be required to assume the role of case managers and to become more flexible through cross-training. Nurses are expected to be concerned with keeping hospital costs down while maintaining the quality of care. Many suggest that the future of nursing may depend on how well nurses can demonstrate their value and cost-effectiveness.

Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) have emerged as alternative medical care delivery systems. Insurers and providers of care have united to hold costs down yet remain competitive. Historically, a two-tiered system evolved: one tier (private insurance, HMOs and PPOs) served people with greater financial resources, and the other tier (Medicare and Medicaid) served people with fewer resources. With recent federal legislative changes, a large percentage of persons who were uninsured will have access to health care via the Healthcare Reform Act of 2010. Box 1-3 defines managed care systems.

Nursing Care

Procedural modifications for the nurse have been made, including adherence to standard precautions during the labor and delivery process (see Appendix A), during umbilical cord care, and in the nursery. More emphasis on data entry and retrieval makes it necessary for nursing personnel to be computer-literate. Sociologically, families have become smaller, the number of single parents is increasing, child and spouse abuse is rampant, and more mothers work outside of the home to help support the family. These developments present special challenges to maternal and child health nurses. Careful assessment and documentation to detect abuse are necessary, and nurses must be familiar with community support services for women and children in need. Nurses must also be flexible and promote policies that make health care more available for working parents. Teaching must be integrated into care plans and individually tailored to the family’s needs and its cultural and ethnic background.

Health Care Reform

The revolution in health care involves the conflict between cost containment and quality of care. When health care became a profitable business industry, cost containment and managed care were born. Managed care openly evaluates care given and can result in increased quality. Quality assurance committees are investigating the routine management of patients, especially in the area of preventive care and tests.

The federal government enacted a health care reform plan in 2010 to reduce the cost of health care while making it more accessible to all. Access to care also depends on the availability of resources within a community. Figure 1-3 demonstrates that as of 2004, there are many areas within the United States that do not have adequate resources for maternal-child health care.

Health insurance plays an important role in health care delivery. Having health insurance does not necessarily ensure access to care, since the insurance company often must approve (or deny) the expenditure before a test or care is provided. Historically, families that could not afford health insurance often did not seek preventive health care such as prenatal care, infant immunizations, and well-baby check-ups. The Healthcare Reform Act of 2010 helps to facilitate access to healthcare that was previously unavailable. Managed care and utilization review committees that review the appropriateness of health care services also have an impact on physicians’ management of patients. Continued study is needed to determine the effect of managed care on the quality of health care and cost containment. Nurses are involved in the health care reform movement as patient advocates to ensure quality of care.

Future Roles for Nurses

The future role of the nurse will involve providing health care in a variety of settings and working closely with the multidisciplinary health care team. The nurse will function as a caregiver, teacher, collaborator, advocate, manager, and researcher. Competence in care and accountability to patient, family, community, and profession are core responsibilities of the nurse in the twenty-first century. Nurses will take a key role in shaping the health care picture of tomorrow.

Healthy People 2020

Healthy People 2020 updates the previous decade’s statement of national health promotion and disease prevention objectives facilitated by the federal government (U.S. Department of Health and Human Services, 2010). The report identifies objectives designed to use the vast knowledge and technology of health care that was developed in the twentieth century to improve the health and quality of life of Americans in the twenty-first century. The objectives fall under broad categories of effort: health promotion, health protection, preventive services, and the development of surveillance and data systems. The specific goals include increasing the span of healthy life, reducing health disparities among Americans, and achieving access to preventive care for all Americans. Some priority areas include maternal and infant health, immunizations, prevention of sexually transmitted infections, oral health, nutrition, and physical fitness. It is a “vision for the new century” to achieve a nation of healthy people (see Health Promotion box on p. 11).

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