Module 1 Flashcards
- The Direction of Communication between Provider and Patient
- A Predominant Focus on the Physical Versus Psychological Needs
- The Increasing Attentiveness to Risk
- Additive Expectations for Prenatal Care
- Lack of a Broad Health Promotion Focus
- Inconsistent Endorsement of Component Parts of Prenatal Care
- Lack of Attention to Prenatal Education
7 themes of prenatal care identified by Hanson et al. (2009)
What populations of women are most at risk for adverse obstetrical outcomes?
- Women < 20 years old
- non-Hispanic Black, American Indian, Alaskan Native
- inadequate prenatal care
“The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”
maternal mortality (WHO)
“Death from obstetric causes <42 days postpartum, per 100,000 live births.”
maternal mortality rate/ratio (CMQCC)
The number of neonatal deaths (death during the first 28 days of life) per 1000 live births
neonatal mortality rate
number of deaths of infants under one year of age per 1,000 live births.
infant mortality rate
The number of perinatal deaths (stillbirths or death of a live newborn within the first 7 days of life) per 1000 total births
perinatal mortality rate
- Early and Continuing Risk Assessment
- Health Promotion (including Preconception Visit)
- Medical and Psychosocial Interventions
- Standard Documentation
- Expanding Objectives to include the Health of the Childbearing Family through the Year following Birth
- Recommendations for Future Research.
6 themes of prenatal care as identified in the document Caring for Our Future: The Content of Prenatal Care (1989)
structural barriers to receiving prenatal care
- impersonal service from providers
- clinical too far away
- long wait times
financial barriers to receiving prenatal care
- lack of insurance
- no transportation
- cannot get off work
interpersonal barriers to receiving prenatal care
- unplanned or unwelcome pregnancy
- prior healthy pregnancy without problems so care is undervalued
- personal problems
- substance use
“The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.”
pregnancy related death (WHO)
Determine health of mom & fetus Determine risk assessment Obtain history & physical Get lab work Determine gestational age Initiate plan for continuing care Establish a relationship Report unusual changes to minimize or prevent problems
Purpose of Prenatal Care
Typical Routine Labs of Initial Prenatal Visit
CBC blood type & Rh+ antibody screen serology: RPR or VDRL HBsAG HIV (option to opt-out) Rubella Urine Gonorrhea & Chlamydia
Possible Labs of Initial Prenatal Visit
Pap smear (depends on age & date of last one) Wet mount TB test (if high risk) Hgb electrophoresis for sickle cell 1 hr GTT if high risk
Optional Labs of Initial Prenatal Visit
Genetic testing
Cystic fibrosis screening
Nutrition & weight gain guidelines What to expect in the next 4 weeks Inform about fetal development Heartbeat heard at next visit (usually heard between 11-12 weeks) Relief for common discomforts Genetic testing Childbirth prep Overview of practice & visit schedule Phone numbers - when to call, off hours When to revisit, need to call with labs?
Plan for Initial Prenatal Visit
How did she know she was pregnant
Planned vs. unplanned
Wanted vs. unwanted
Dating questions: LMP, menstrual history
OB/GYN history: prior pregnancies, outcomes
med/surg: allergies, illness, surgeries, etc
Family history: both OB & non OB related
Genetic history: primarily immediate family & FOB
Social history: home situation, reactions to pregnancy
Substance history: smoking, alcohol, prescription or illicit drugs
Occupational history: potential exposures, medication supplement history, prenatal vitamins?
Nutritional history
Present pregnancy history: what’s happened, any ER visits, other ultrasounds?
Subjective Data for Initial Prenatal Visit
VS HEENT skin breast abdomen vagina cervix uterus (size, position) FHT lab test that result that day (like a UA)
Objective Data for Initial Prenatal Visit
List with pertinent data points
Ex: G2P1001 IUP at 8 weeks by gestational size & dates
Assessment for Initial Prenatal Visit
Update history with any problems since last visit, feeling of being pregnant, weight gain, family & work balance
Subjective Data for Subsequent Prenatal Visits
BP weight gain < 12 weeks bimanual exam of uterus Assess fundus growth Fetal weight estimate Fetal position
Objective Data for Subsequent Prenatal Visits
12 weeks abdominal palpation of uterus at symphysis
16 weeks uterus ½ way between symphysis & umbilicus
20 weeks fundus at umbilicus
At 20 weeks measure with tape measure in cm with 2 cm being above or below the number of weeks
Fundal growth assessment
Optional quad screen (AFP, hCG, Estriol, and Inhibin-A) as needed
Optional genetic anomaly ultrasound with informed consent
evidence shows routine ultrasounds at 20 weeks does not influence outcomes, okay for patients to decline
2nd trimester 15-20 weeks Optional Objective Data for Subsequent Prenatal Visits
1 hour glucose test
Hct & Hgb recheck - may need to supplement with iron
Sign up for childbirth preparation classes
Discuss warning signs for preterm labor
Antibody screen & rhogam for Rh negative women at 28 weeks
2nd trimester 24-28 weeks Optional Objective Data for Subsequent Prenatal Visits
BP, weight, FHTs, uterine growth, interval history risk assessment
Assess learning at childbirth prep classes
Provide birth resources - assess birth preparation strategies (birth plan, doula) & instill confidence!
34-36 weeks
Teach fetal movement counting
35-37 weeks
GBS
Repeat CG & chlamydia
36-40 weeks
Assess fetal position & estimated fetal weight
40 + weeks
Fetal surveillance
3rd trimester Prenatal Visits
These vary in terms of content accuracy & the philosophical underpinnings with which the info is presented
Can be deceiving compared to the reality of American birth practices
Childbirth Books
How do women learn about pregnancy and birth?
Through their healthcare professionals (most impt source)
Child education classes
Internet
Child Birthing books
Provide an interpreter if needed
Inform the woman about maternity care models
Provide printed information about maternity care, preferable in woman’s native language
Encourage the woman to ask questions
Reassure the woman that she has a choice regarding a model of care or specific intervention
Ask the women about her cultural views regarding pregnancy
How can midwives/WHNPs demonstrate cultural humility in prenatal care
How does the midwifery model of care differ from other models?
Midwives are experts in normal pregnancy and in meeting the other needs of pregnant women—the needs that are not related to pathology
Shared Decision Making Components
Collaboration between provider & patient
Education based on evidence
Consideration of the patient’s values & preferences
Discuss all options
Discuss of risks & benefits
S.H.A.R.E. Approach to Shared Decision Making
S: Seek your patients participation
Communicate that a choice exists & invite
your patient to be involved in the decisions
H: Help your patient explore & compare
treatment options
Discuss the benefits & harms of each option
A: Assess your patient’s values & preferences
Take into account what matters most to your
patient
R: Reach a decision with your patient
Decide together on the best option &
arrange for a follow up visit
E: Evaluate your patient’s decision
Plan to revisit the decision & monitor its
implementation
Professional competence on the part of any team member, you cannot trust a team member if you don’t trust her or his skills
A common orientation to the patient as the primary unit of attention
Acknowledgement of interdependence
A formal system of communication between providers
Face to face regular meetings, encourage effective communication
Team leaders who are effective communicators
How midwives can work successfully in an interprofessional team
Data collection
Subjective/Objective
Data assessment
Normal vs. abnormal
Plan
Planned decision making/consultation if needed
Evaluate Outcomes
Successful plan/consider alternatives when neededSteps in the Midwifery Management Process
Implemented in 1993 by Sharon Schindler Rising
8-12 women with similar due dates join a group after initial visit
Women measure own weight, BP, gestational age
Concerns, questions addressed, healthy snacks available, creates socialization
Based on health care, interactive learning & community building
Centering Pregnancy
The language we use when talking with women can convery decision making power in care
Women often have a self perception risk that is higher than the actual risk
Effects of language midwives use on women’s perceptions and outcomes
usual schedule for prenatal visits Conception - 28 weeks
every 4 weeks
usual schedule for prenatal visits 28-36 weeks
every 2 weeks
usual schedule for prenatal visits 36 weeks - Birth
weekly
Health education that prepares women for likely pregnancy experiences both physically & emotionally
anticipatory guidance
When should clinicians ideally begin the process of risk assessment related to pregnancy?
Ideally prior to conception and at each encounter starting with initial visit
(Obtained through history (subjective), physical (objective) & labs)
risks and benefits of risk assessment
To predict those who will have an adverse event in order to intervene & prevent an adverse event
Not always positive/helpful - having a risk factor does not mean the patient will automatically experience a poor outcome or a complication
risk of developing the disease over a period of time, **probability event will occur
absolute risk
estimate of the probability of an adverse event for one group relative to another
used to compare 2 different groups of people, tells you nothing about actual risk
Example: smokers vs. nonsmokers - does belongings to a group increase or decrease your risk of developing certain diseases
relative risk
absolute or relative risk…which is better?
absolute risk
adverse events that can be directly attributed to the risk factor itself
attributable risk
barriers that cannot be changed (Age, socioeconomic status, race)
non-modifiable risk factors
barriers that CAN be changed (Nutrition, weight, exercise)
modifiable risk factors
Proportion of positive screens among those known to have the condition being screened for
Ability of a test to correctly classify an individual as “diseased”
Sensitivity
Proportion of negative screens among those known not to have the condition being screened for
Specificity
The true positives among all those with positive screens; reflects the probability that a positive test reflects actually having the underlying condition being tested
Positive predictive value
The true negatives among all those with negative screens; reflects the probability that a negative test reflects not having the underlying condition being tested
**The probability that having a negative test result accurately reflects the absence of the underlying condition being screened for.
Negative predictive value
When a woman takes an action to which she has been directed towards by the provider, rather than making a choice
Informed compliance
Healthcare provider, providers complete information in an understandable format
Not signed document, it is a process of communication & exchange between a women & her healthcare provider to foster her ability to make the best decision about her own health care
Informed consent
Information framed by the provider towards offerings superior choice over another to avoid provider-perceived risk
Illusion of choice
possible signs of pregnancy
subjective signs experienced by the mother
probably signs of pregnancy
objective signs the provider assesses
positive signs of pregnancy
signs that result from the fetus itself
- respond to the woman’s specific questions
- address essential health and safety issues
- provide anticipatory guidance about pregnancy changes, birth, and infant care
- add explanations on topics or policies beyond the woman’s self-identified needs
The four priorities in providing prenatal education as described by Roberts (1976)
Adverse events that can be directly attributed to the risk factor itself.
attributable risk
What does a test with a higher negative predictive value tell a woman?
Women who don’t have the condition being screened for will only rarely receive a positive result on the screening test. (A negative test result on a screening test with high negative predictive value essentially rules out the condition being screened for.)
The probability that having a positive test result accurately reflects the presence of the underlying condition being screened for.
positive predictive value
When a woman takes an action to which she has been directed towards by the provider.
informed compliance
The estimated probability of an adverse event in one group when compared to another group.
relative risk
An attribute, characteristic, or exposure that increases the likelihood of developing a disease or injury.
risk factor
The proportion of positive screens among those known to have the condition being screened for.
sensitivity
The proportion of negative screens among those known not to have the condition being screened for.
specificity
When information about risk is framed by the provider in such a way as to favor one choice over another.
illusion of choice
Providing women with complete information in a format they can understand so they can make the best decision for themselves.
informed consent
What can help improve future attendance at the 1st prenatal care visit?
taking the time to get to know her and making her next appointment with you.
program that promotes the woman as an expert on her pregnancy
Centering Pregnancy
The relationship of risk factor to adverse event is?
a statistical probability
components of risk assessment
history, physical, lab data
___________ and __________ data gathering is the best risk screening in pregnancy
medical and psychosocial
what can convery decision-making power in care to childbearing women?
the language we use
this can maintain medical authority over childbirth knowledge
risk assessment in pregnancy
women often have a self-perception of risk that is __________ than actual risk
higher
goal of prenatal care in the Midwifery Model of Care
make the woman an expert on her own pregnancy
Defining pregnancy as “risky” has caused?
women to surrender control of pregnancy choices to medical professionals
number of women with a positive screening test who actually have the condition
sensitivity
Impact of ____________ screens on healthy women:
additional testing
increased anxiety
labeling of woman as “diseased
false-positive
Telling the woman what tests will be performed throughout her pregnancy at the first prenatal visit including CF testing and HIV testing that day, a Quad Screen at 16 weeks, and a GBS screen at 36 weeks is an example of:
informed compliance
Attendance at prenatal care visits and perinatal outcomes in African American women have been found to be significantly improved by?
trust in the woman-provider relationship
demonstration of care by the provider
maintaing effective communication
Attendance at prenatal care visits and perinatal outcomes in African American women have NOT been found to be significantly improved by?
offering visits outside of regular business hours
