Reproductive Health and Newborn Nursing 12 Flashcards
Part 1: Trends in Childbirth
Overview of the history of childbirth in the U.S.
Review of trends in current practices in childbirth and economics related to healthcare during the perinatal period.
Review of factors affecting current practice.
The way that you have a baby has never changed.
Trends in Obstetrics and Newborn Care
Timeline of Childbirth Care in the U.S.:
Colonial America through the 1800s:
- Women in childbirth attended at home by other women and members of their communities.
1847:
- Anesthesia introduced, representing a significant advancement in medicine.
- It was initially rudimentary and started being used in childbirth via chloroform.
1900s:
- 90-95% of babies were born at home with the assistance of midwives.
1920s:
- Births shifted from home to hospitals.
- Introduction of “Twilight Sleep,” which is a form of what we now recognize as moderate sedation.
1930s:
- A 50/50 split between home births and hospital births.
- Midwives attended 15% of births.
1940s:
- By the end of the decade, 87% of births occurred in hospitals.
- Individuals with fewer resources continued to have home births.
1847 : Anesthesia first introduced into
1900′s : In the United States, most babies were born at home. (90-95%)
1920′s :
Births moved from home into hospitals for those that could afford it and those who would like medication during childbirth.
“Twilight Sleep” is introduced in the United States
1930′s : Births become split 50/50 between hospitals and home, number of births attended by midwives drops to 15%.
1940′s. In the 1940 forceps were also introduced because women were so sedated (twilight sleep) that they couldn’t push.
Trends:
Hospital Birth Practices
1940s:
- Women labored in large maternity wards and were advised to remain quiet.
- Women delivered in sterile delivery rooms with only medical staff present, following the introduction of modern techniques.
- Routine enemas and pubic shaving were common practices.
- A 10-day hospital stay on bedrest was standard.
- The lithotomy position was frequently used, and forceps were frequently employed during delivery.
- Mothers were separated from their babies as a precaution against infection. Babies were brought to see their mothers periodically every 3 to 4 hours for feeding.
1942:
- Grantley Dick-Read, a British author, published “Childbirth Without Fear.”
video slide 7
1950s:
- 95% of women gave birth in the hospital, nearly reaching 100%. The remaining 5% typically resided in rural areas, often in the South.
1960s:
- Episiotomies became routine during childbirth.
- Women were advised to be NPO (nothing by mouth) during labor.
- Simultaneously, there was a movement towards natural childbirth and a return to the principles of natural childbirth within the hospital setting.
- Ina May Gaskin
, a hippie from San Francisco, initiated a movement to involve fathers in the delivery room. They traveled in a caravan to Tennessee and founded a community where people could give birth on a farm.
- The International Childbirth Education Association was established.
1977:
- “Spiritual Midwifery” by Ina May Gaskin was published.
1970s:
- Fathers were allowed in the delivery room.
- Continuous fetal monitoring was introduced and became more prevalent.
1979:
- 99% of all births took place in hospitals.
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Trends in Obstetrics and Newborn Care video 9
“Husband-Coached Childbirth”
video 10
Trends: Where are we
now?
Who Delivers Care?
- Obstetricians: Most individuals receive care from obstetricians who specialize in pregnancy and childbirth.
- Physicians with Childbirth Training: Some care is provided by physicians who have received specialized training in childbirth.
- Certified Nurse Midwives: Certified nurse midwives also play a significant role in delivering care during childbirth.
Childbirth Trends:
- Childbirth trends can vary, but they often reflect changes in medical practices, preferences, and societal norms related to childbirth.
Usual Hospital Stay:
- The usual hospital stay for someone giving birth has evolved. It has changed from a previous standard of 10 days to approximately 2 days. In cases of uncomplicated deliveries, some patients may be discharged within 24 hours, while for c-section deliveries, the hospital stay may extend to around 3 days. The goal is to avoid prolonged bed rest for patients.
Economics and Systems of Healthcare:
- The economics and systems of healthcare play a crucial role in determining access to and quality of childbirth care. Factors such as insurance coverage, healthcare providers, and healthcare policies impact the childbirth experience.
Role of Technology:
- Technology has a significant role in modern childbirth care. It includes the use of medical equipment for monitoring, diagnostic tools, and surgical procedures. Technology can enhance safety, improve outcomes, and provide valuable data during childbirth.
Initiatives:
- Initiatives in childbirth care can include efforts to improve maternal and infant health, reduce disparities, enhance access to care, and promote evidence-based practices. These initiatives may be undertaken by healthcare organizations, government agencies, advocacy groups, and healthcare professionals to advance the quality of childbirth care.
Current Trends:
Who & Where
Practitioners:
OB/GYN
CNM
FHP
Locations
Hospital
Homebirth
Birth Centers
Trends: Current Practices
Family-Centered Care:
- Family-centered care is an approach to healthcare that recognizes the importance of involving and supporting the entire family in the care of a patient. In the context of childbirth, it emphasizes the inclusion of partners, siblings, and other family members in the birthing process and decision-making.
Evidence-Based Practice:
- Evidence-based practice in healthcare involves using the best available research, clinical expertise, and patient preferences to guide healthcare decisions and practices. It ensures that healthcare interventions and treatments are based on scientifically proven methods and outcomes.
Informed Decision Making and Education to Reduce Fear:
- Informed decision-making is a fundamental aspect of patient-centered care. It involves providing patients and families with accurate information about their healthcare options and potential risks and benefits. In the context of childbirth, informed decision-making can help reduce fear and anxiety by empowering individuals with knowledge about their choices.
- Fear during childbirth can trigger the body’s fight-or-flight response, leading to physical tension, which can hinder the natural progression of labor. Educating and informing expectant parents about childbirth can help alleviate these fears, promoting a more relaxed and positive birthing experience.
- Ina May Gaskin’s concept of “sphincter law” underscores the importance of relaxation and reducing fear during childbirth. According to this concept, when women are relaxed and free from fear, their body’s natural processes, including the relaxation of sphincter muscles, can occur more smoothly, facilitating the birthing process.
Trends:
Family- Centered Care
The principles of family-centered maternity care, as outlined in the provided document, encompass the following key elements:
- Respect:
- Respect involves recognizing the dignity and autonomy of both the birthing process and parents. Healthcare providers should honor the choices and preferences of expectant parents while ensuring their voices are heard and valued.
- Openness:
- Openness in family-centered care fosters collaboration and information sharing. It encourages healthcare professionals to work together with parents, offering transparency in decision-making processes and sharing pertinent information.
- Confidence:
- Confidence in family-centered care is about supporting parents throughout the childbirth journey. Healthcare providers should instill confidence in expectant parents by providing emotional support and reassurance during pregnancy, labor, and postpartum.
- Knowledge:
- Knowledge in family-centered care emphasizes the importance of evidence-based practices and options. Healthcare providers should stay informed about the latest research and best practices to offer expectant parents the most up-to-date information and choices regarding their care.
- Atmosphere:
- The atmosphere in family-centered maternity care is ideally family-centered and supportive. However, it’s important to note that the COVID-19 pandemic has affected the traditional atmosphere of childbirth, often necessitating safety precautions and visitor restrictions. Nevertheless, healthcare providers strive to create an environment that is as welcoming and family-oriented as possible under these circumstances.
For more in-depth information on these principles and their application in maternity care, you can refer to the provided document: Family-Centered Maternity Care.
Trends:
Family Centered Care
In the context of childbirth and maternity care, several important factors and considerations are highlighted:
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Patient Empowerment in Pain Management:
- Empowering patients to make their own decisions regarding pain management is a fundamental aspect of patient-centered care. It recognizes that expectant parents have unique preferences and tolerance levels for pain during labor and childbirth. Healthcare providers should offer a range of pain management options and respect the choices made by patients.
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Doulas:
- Doulas are trained professionals who provide emotional and physical support to expectant parents during labor and childbirth. They play a valuable role in providing continuous support, offering comfort, and helping to advocate for the birthing person’s preferences. Some hospitals don’t appreciate their presence.
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Choice of Provider:
- Offering expectant parents a choice of healthcare provider, such as obstetricians, certified nurse midwives, or family practitioners, allows individuals to select a provider whose approach aligns with their values and preferences.
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Choice of Birth Location:
- The choice of where to deliver, whether it’s a hospital, birthing center, or home, is a significant decision for expectant parents. This choice can impact the birthing experience and the level of medical intervention available. It’s important for patients to have the option to choose a setting that aligns with their birth plan and comfort.
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Breastfeeding:
- Promoting and supporting breastfeeding is a critical aspect of maternity care. Healthcare providers should offer education and support to encourage breastfeeding, recognizing its numerous health benefits for both infants and mothers.
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Regional and Hospital Variations:
- The options and culture surrounding childbirth can vary regionally and among hospitals. Different regions and healthcare facilities may have different protocols, practices, and cultural norms related to childbirth. Expectant parents should be aware of these variations and have the opportunity to make informed choices that align with their preferences.
Trends: Length of Hospital Stay
The provided timeframes for postpartum hospital stays are common guidelines for maternity care:
- Vaginal Birth: Typically, a hospital stay of 24 to 48 hours is common following a vaginal birth. The exact duration can vary depending on the individual’s health, the baby’s health, and the specific hospital policies.
- Cesarean Section (C-Section): For those who undergo a cesarean section, the hospital stay is often longer, ranging from 48 to 72 hours. This extended stay allows for monitoring and recovery following surgery.
- Focus on Outpatient Education: Outpatient education is essential in preparing expectant parents for childbirth and postpartum care. Providing comprehensive education during prenatal care visits helps parents understand what to expect during labor, delivery, and the postpartum period. This education empowers them to make informed decisions and take an active role in their healthcare.
Trends: Economic of Childbirth and Health Care Systems
Childbirth and Hospitals:
- Childbirth is economically lucrative for hospitals.
- Most childbearing individuals have insurance coverage, and if not, they are covered by medical programs.
- Hospitals consider childbirth a service with guaranteed reimbursement.
- Historically, when someone gave birth at a hospital, they were more likely to continue using that hospital for their future healthcare needs.
Fragmented Care:
- Childbirth can be expensive, especially for those without insurance.
- Limited choices in childbirth options are often linked to the cost.
- Most insurance plans do not reimburse for home births due to cost considerations.
Liability Concerns:
- In some states, numerous malpractice lawsuits have led physicians to intervene more than necessary out of fear of being sued.
Trends: Health Care Systems
Patient Protection and Affordable Care Act (ACA):
- The ACA mandates that breastfeeding individuals must be provided with a breast pump.
- In our state of California, medical facilities are required to adhere to this standard.
- Consequently, all our patients are eligible to receive an electric breast pump delivered to their homes.
Key ACA Objectives:
- Enhances the affordability of insurance.
- Implements measures to contain healthcare costs.
- Strengthens and enhances the Medicare and Medicaid programs.
- Includes provisions aimed at promoting prevention and public health.
Trends Related to the Patient Protection and Affordable Care Act (ACA):
- Mandates coverage of maternity care and childbirth by all qualified health plans.
- Provides coverage for 22 preventive services for women, extending beyond childbearing and including breastfeeding benefits, as mentioned earlier.
- Requires health insurance plans to offer breastfeeding support, counseling, and equipment throughout the breastfeeding period.
- The ACA amended the Fair Labor Standards Act (FLSA), obligating employers to provide adequate break time for mothers to pump breast milk in a location that is not a restroom.
Trends:
Fetal Monitoring has really changed labor
It’s fascinating to see how fetal monitoring has evolved over the years and its impact on labor and delivery. Here’s a breakdown of the trends you mentioned:
- Fetoscope (1917, Chicago): The use of a fetoscope, a simple acoustic device, marked an early attempt to monitor fetal well-being during labor. It allowed healthcare providers to listen to the fetal heartbeat indirectly.
- 1940s: Electronic amplification of auscultation (IA standard of care): During the 1940s, electronic amplification of fetal heart sounds became the standard of care. This advancement improved the accuracy of fetal heart rate monitoring during labor.
- 1968: EFM available in the U.S.: Electronic fetal monitoring (EFM) became available in the United States in 1968. EFM involves the use of specialized equipment to continuously monitor the fetal heart rate and uterine contractions during labor.
- 1972: Fetal scalp electrode introduced: The introduction of the fetal scalp electrode further improved the accuracy of fetal monitoring by allowing direct measurement of the fetal heart rate.
- 1975: 20% of labors monitored by EFM: By 1975, a significant portion of laboring women were being monitored using EFM, indicating its growing acceptance and use in clinical practice.
- 2023: Majority of labors monitored by EFM: As of 2023, the majority of labors are monitored using EFM, highlighting its widespread adoption in modern obstetric care.
EFM provides valuable information about fetal well-being, including oxygenation, acid-base status, and the condition of the central nervous system. However, your statement highlights an important consideration:
“What we want is a decrease in the rate of birth injury and specifically cerebral palsy, has it done so in low-risk populations. It has not.”
This statement raises concerns about whether the widespread use of EFM has led to the desired reduction in birth injuries, particularly cerebral palsy, in low-risk populations. Cerebral palsy is a complex condition with multifactorial causes, and while EFM provides important data, it may not be the sole factor influencing its incidence.
The effectiveness of EFM in reducing birth injuries and cerebral palsy rates is a topic of ongoing research and debate in the field of obstetrics. Factors such as the interpretation of EFM tracings, interventions based on monitoring findings, and overall obstetric care practices can all play a role in outcomes.
It’s essential for healthcare providers and researchers to continue studying the impact of EFM on birth outcomes and make evidence-based decisions regarding its use in different clinical scenarios. Additionally, considering the unique circumstances and risk factors of individual pregnancies is crucial in providing the best possible care to expectant mothers and their babies.
Trends: Fetal Monitoring
- Small decrease in rates of neonatal seizures: EFM has been associated with a small decrease in the rates of neonatal seizures. This suggests that continuous electronic monitoring may help detect and address fetal distress in some cases, reducing the risk of certain neonatal complications.
- No benefit for low-risk birthing people: Interestingly, EFM does not appear to provide significant benefits for low-risk individuals during labor. This indicates that the continuous monitoring may not offer substantial advantages over intermittent auscultation in this population.
- No decreased rates of cerebral palsy/birth injury: Contrary to some expectations, the use of EFM has not been shown to result in decreased rates of cerebral palsy or birth injuries. These outcomes are influenced by various factors beyond fetal monitoring, highlighting the complexity of birth-related complications.
- Decreases a laboring person’s mobility: Continuous electronic fetal monitoring can limit a laboring person’s mobility because they are tethered to monitoring equipment, which may restrict their ability to move around during labor. Mobility can be important for comfort and progression of labor.
- Increases the chances of instrument-assisted births: EFM has been linked to an increased likelihood of instrument-assisted births, such as forceps or vacuum extraction. This may be due to the additional information provided by continuous monitoring, which can prompt interventions.
- Linked to increased rates of operative birth (C-sections): EFM has also been associated with higher rates of operative births, including cesarean sections (C-sections). Continuous monitoring may lead to interventions that ultimately result in the need for surgical delivery.
It’s important to note that these findings are based on the most recent information available as of 2023 from sources like the American College of Obstetricians and Gynecologists (ACOG) and the National Institutes of Health (NIH). The use of EFM or IA during labor is a complex decision that depends on various factors, including the risk profile of the individual, the clinical situation, and the preferences of the birthing person.
Ultimately, healthcare providers should weigh the benefits and risks of each monitoring method and make informed decisions to provide the best care for both the birthing person and the baby while considering individual circumstances. It’s also important for ongoing research and guidelines to inform obstetric practices to optimize outcomes.
Trends: C-Section
Evolution of C-Sections and Birth Culture:
- With advancements in anesthesia techniques and the introduction of low-transverse incisions in 1926, cesarean sections (C-sections) became a more viable option for childbirth.
- Prior to 1965, the C-section rate was less than 5% (NIH, 2023).
- In 2021, the C-section rate increased to 32.1% (CDC, 2023).
- It’s important to note that birth culture can vary significantly from one hospital to another and from one state to another, impacting the choice of childbirth methods and interventions.
Check slide 23
Trends: Technology in Childbirth
Advances in Scientific Knowledge and Medicalization of Birth:
- Advances in scientific knowledge have led to a healthcare system that emphasizes high-technology care and monitoring.
- It’s important to recognize that every approach, including high-technology care, comes with both advantages and disadvantages.
- With the shift of childbirth to the hospital and its increasing medicalization, there has been a corresponding rise in the application of interventions and technologies during the birthing process.
- Simultaneously, there has been an uptick in high-risk pregnancies, reflecting the evolving landscape of modern maternity care.
Trends: Increasing Rate of AMA
Increasing Challenges with Maternity Care:
- There is a noticeable increase in patients aged 35 years and older, which introduces a distinct set of pregnancy complications.
- Additionally, this demographic shift is associated with higher risks such as pre-existing diagnoses, spontaneous abortion (SAB), gestational diabetes mellitus (GDM), chronic heart disease, and chromosomal anomalies.
- Importantly, it’s worth noting that these conditions are not exclusive to older patients and can affect younger patients as well, highlighting the complex and varied nature of pregnancy-related health challenges.
Trends:Increasing Number of Pregnant People with Chronic Health Conditions
Diabetes
Hypertension
Chronic Heart Disease
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Diabetes in Pregnancy:
- Gestational Diabetes: Some pregnant individuals develop diabetes during pregnancy, known as gestational diabetes. It can lead to complications if not managed properly.
- Pre-existing Diabetes: Women with pre-existing diabetes (Type 1 or Type 2) face increased risks during pregnancy, including birth defects, macrosomia (large baby), and preeclampsia.
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Hypertension in Pregnancy:
- Preeclampsia: High blood pressure during pregnancy can lead to preeclampsia, a condition characterized by high blood pressure and damage to organs, often affecting the liver and kidneys. It can be life-threatening for both the mother and baby if left untreated.
- Chronic Hypertension: Women with chronic hypertension before pregnancy may require careful monitoring and management to prevent complications.
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Chronic Heart Disease in Pregnancy:
- Women with pre-existing heart conditions may face increased risks during pregnancy due to the added strain on the cardiovascular system.
- Close monitoring and coordination between obstetricians and cardiologists are essential to ensure the safety of both the mother and baby.
Part II:Health Disparities
- In general, the United States has the highest maternal morbidity rates among developed nations.
- Health disparities refer to preventable differences in the burden of disease, injury, violence, or opportunities to attain optimal health. These disparities are experienced by socially disadvantaged groups and are inequitable. They are directly linked to the historical and current unequal distribution of social, political, economic, and environmental resources.
For more information, you can visit the provided CDC link: CDC Health Disparities Information.
Health Disparities: Maternal Morbidity and Mortality
Maternal Morbidity and Mortality in the United States:
- The United States has the highest rate of maternal morbidity and mortality among wealthy, post-industrial nations.
- Maternal morbidity and mortality serve as crucial health indicators for the entire population.
- Black and indigenous childbearing individuals face significantly higher risks regarding maternal morbidity and mortality.
- Between 2000 and 2014, reported cases of maternal morbidity doubled, likely due to a combination of factors, including the rise in chronic health issues.
- The effects of systemic racism, healthcare bias, and the concept of “weathering” (which refers to the accelerated aging of individuals from disadvantaged populations) are subjects of active study to gain a better understanding of their impact on maternal health disparities.
- Grassroots movements, government initiatives, and professional organizations are actively collaborating to discover solutions and address these disparities, with the goal of improving maternal health outcomes for all.
