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Current Issues in Maternal-Newborn Nursing:


Current Issues in Maternal-Newborn Nursing: No More Octamom! AI,ART and Surrogate Childbearing Legal problems with AI (TI) using donor sperm Donor must sign a form ... – PowerPoint PPT presentation

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Title: Current Issues in Maternal-Newborn Nursing:

Current Issues in Maternal-Newborn Nursing
  • No More Octamom!

What Are Current Issues in Maternal-Newborn
Maternal Mortality
  • 28 countries have lower maternal mortality rates
    than the US
  • MM of women dying around the time of childbirth
  • US ranks 41st in the world (Amnesty
  • 37th (Lancet)
  • An American woman is at least twice as likely to
    die in pregnancy or childbirth as a woman in much
    of Europe.

The Numbers
  • Every year at least 1,000 women die around the
    time of birthing
  • That is 3 jumbo jets full of our sisters,
    daughters and mothers

Maternal Mortality
  • Lifetime risk of a maternal death during or
    shortly after pregnancy is 1 in 17,400 in Sweden
  • 1 in 8 in Afganistan 2
  • 1 in 7 in Niger 1

  • Hemorrhage 1 cause of maternal death
  • Community based distribution of misoprostol
  • 3 little pills after you deliver the baby
  • http//
  • Is there a connection between hypocalcemia and
    preeclampsia, can we distribute calcium to the
    general public cheaply? Yes 0.92 for 100
    sachets of calcium to sprinkle on food.

Be the change that you want to be in the
world. Gandhi
  • Its Global
  • One woman dies every minute from a pregnancy
  • 300,000
  • Most die in developing countries
  • One woman dies every 2 minutes from cervical
    cancer, 80 in the developing world
  • 10,000 pregnant women die each year from Malaria
  • 200,00 newborns die each year from Malaria
  • 60 of adults with HIV in Sub-Saharan Africa are

Why? So high in the US
  • Two to three women die every day due to
    pregnancy-related complications
  • The three leading causes of maternal death
    nationally are
  • Eclampsia/Pre-eclampsia
  • Embolism
  • Hemorrhage

Need Collaborative Approaches to Early
Identification and Treatment
  • Risk assessment and preparation for possible
    hemorrhage, EBL, tx of hemorrhage, hypovolemia,
    development and implementation of Rapid Response
  • Education and simulation drills.

Why study maternal M M
  • Evidence suggests that at least one half of
    pregnancy-related deaths may be preventable
  • through changes in patient, provider, or
    system factors.
  • Mortality is disproportionally high among certain
    racial and ethnic groups.
  • Deaths are only the tip of the iceberg morbidity
    represents a huge burden of disease for women and
    their families.

The Babies
  • 41 countries have lower infant mortality rates
    than the US
  • Infant mortality babies dying before their
    first birthday
  • US ranks 31st of developed nations, falling
    behind South Korea, Cuba, Czech Republic

Infant Mortality
  • 2 per 1,000 live births in Iceland
  • 120 per 1,000 live births in Mozambique

Power of Nurses
  • 70-80 of the health care work force is nurses
  • 85 of the health care workforce in rural Africa
    is nurses.

Colorado Statistics
  • LBW less than 5.8 pounds
  • National average is 8.3
  • Colorado is 9.6
  • Some of the top rated states are as low as 6

  • B4Babies a program in
  • Mesa County has
  • given the county the
  • best ranking in the state 8.4
  • Offers every type of care an expectant mother
    could need help filling out applications for
    financial assistance, help with medical
    appointments, translation, transportation
  • Started 19 years ago
  • Recognized by HHS in 1998 as a Model that Works

Costs for LBW babies in CO
  • 10,000 per day
  • March of Dimes has tallied the average cost
    nationally for the first year of life for LBW
    babies beyond intensive care at 49,000
  • Prenatal care and education that helps expectant
    mothers stop risky behaviors is vastly cheaper
    than paying for the care of babies with problems

Colorado Infant Mortality
  • The infant mortality disparity seen nationwide
    among Black
  • infants is observed in Colorado as well, and
    has been present
  • over time.
  • In 2006, the infant mortality rate among Black
    infants in Colorado was 12.4 per 1,000 live
    births to Black mothers while that among
    White/non-Hispanic infants was 5.0

Women of Color in Colorado
  • After controlling for maternal age, education,
    prenatal care, short gestation and low birth
    weight, multiple births, medical risk factors,
    and labor and delivery complications, Black
    mothers still had 50 percent greater odds of
    infant death compared to White/non-Hispanic
    mothers (Odds Ratio 1.5, 95 Confidence
    Interval 1.3-1.8).

Where We Need to Be
  • The Healthy People 2010 objective for infant
    mortality is
  • less than 4.5 infant deaths per 1,000 live
  • across all race/ethnic groups.

  • Among the myriad possible explanations for the
  • in low-weight births are the use of
    fertility treatments and
  • the increasing rates of multiple births
    (twins, triplets, etc.)
  • Research has shown that both multiple births and
  • births from assisted reproductive
    technologies (ART) have
  • higher risks of low birth weight and
    prematurity compared
  • to infants born without ART.
  • Colorados birth certificate included information
    about ART for the first time in 2007, which will
    allow for further study of this issue both in
    Colorado and nationwide.
  • More about ART later

Millennium Development Goals
  • In 2000, world leaders set far-reaching goals to
    free a major portion of the worlds population
    from poverty, hunger, illiteracy, and disease.
  • Targeted achievement by 2015
  • Halve extreme poverty
  • Halt spread of HIV/AIDS
  • Universal primary education

Povertys Affect on Womens Health
  • 44 Million Americans
  • 1 out of 7 adults, 1 out of 5 children
  • Lack of health insurance
  • 51 Million Americans in
  • 2009

Poverty in CO
  • 12.3 in 2009, the 31st highest in the US
  • 16.3 Colorado poverty rate for children in 2009
  • People living without health insurance in
    Colorado 16

It is Global
  • Poverty, economic development, and the poor
    health of women are a lethal combination of
    elements, left untouched will result in continued
    poor health of families, continued high rates of
    maternal and child mortality and morbidity and
    limited national development in most
    resource-poor countries of the world.

  • Aim of the United Nations Millennium Development
    Goals (MDGs) is to reduce the number of people
    throughout the world who live on less than 1 a
    day by 50, by finding solutions to poverty,
    hunger, disease, illiteracy, environmental
    pollution, and discrimination against women.

Social Issues Affecting Women in Poverty
  • Divorce
  • Lower wages compared with men
  • Public assistance
  • Homelessness

Two thirds of Americans living in poverty are
women and children
Our Children
  • One half of all children in the US and 90 of
    Black children will be on food stamps at some
    point during childhood
  • Children on food stamps are at risk for
    malnutrition and other ills linked to poverty

Temporary Assistance forNeedy Families (TANF)
  • Provides assistance for childcare
  • Promotes job preparation, work, and marriage
  • Reduces the incidence of unplanned pregnancies
  • Encourages two-parent families

Wage Gap
  • 40 of U.S. workforce consists of women (2004)
  • Expanded career options for women
  • Male-to-female earnings ratio is 76.5 (2004)
  • Widest gap is between well-educated women and men
  • Lily Ledbetter Act 1st bill signed by Obama

Lily Ledbetter Act
Causes of Wage Gap
  • Deliberate wage discrimination against women
  • Undervaluing of womens work
  • Womens socialization

Some women rely on the father to provide
full-time child care at home while they pursue
their career. Stay-at-home fathers provide only
1.5 of care to children under the age of 5 in
the United States
Some mothers are able to combine professional
careers with motherhood by telecommuting from a
home office.
Family and Medical Leave Act (1993)
  • 12 weeks of unpaid leave following
  • Birth or adoption of a child
  • Placement of a foster child
  • Also applies to
  • Serious illness
  • Illness of a spouse, child, or parent

Childhood education centers provide preschoolers
with advanced skills for early education and
provide care while parents work outside of the
Ethical Thinking About ART
  • Autonomy right to independently chose health
    care options.
  • Informed Consent risks, consequences, benefits,
    alternatives must be written and spoken in
    language the pt understands. Witnessgt18 (what
    they hear is based on dreams and desires for
    miracles, does not serve us in way we want)
  • Justice equal distribution of lifes good.
  • Canada every person gets equal share of
    health care donor eggs illegal , no free market
  • US according to your effort, free market
    exchange, can buy ART

What Happened at Kaiser Bellflower A just
  • Walkin no clue where she came from
  • Anticipated 7 got 8
  • Had staff of 46 present for scheduled c/s
  • Had to divert admissions and other high risk pts
    to Hollywood
  • 2 nurses, one MD for each baby
  • NICU stay 805,500 to 3 Million
  • 50 (150) employees terminated for looking at the
    chart HIPPA

  • Is this available to every citizen in the U.S.
  • Is everyone due the same?
  • The cochrane library metaanalysis of all data on
    mutiple gestation
  • Findings significant risk of morbidity and
    mortality to both gestation and life of mother
  • Conclusion Regulation was needed
  • Should be based upon pts age and quality of

Regulation in Response to Cochrane
  • Canada
  • England
  • Sweden
  • One Embryo, One Birth (Karlstrom and Bergh,

American Society of Reproductive Medicine 2008
  • Recommend (rather than regulate)
  • Women under the age of 25 should have no more
    than two embryos implanted.
  • Women ages 35-37 should have no more than three
    embryos implanted.
  • Women ages 38-40 should have no more than four
    embryos implanted.
  • Women age 40 and over should have no more than
    five embryos implanted.
  • Yet in U.S. only 0.5-3 of all transfers are
  • Nadia Suleman, a woman under 35 received six
    embryos transferred.

  • Few Families aware of exactly what the procedure
    was and what the consequences were
  • Traumatic, chaotic, depressed disturbing,
    turmoil, guilt
  • Grieving for the lost fetuses simultaneously
    compounded due to constant reminder of the
    non-reduced infants
  • Even when positive outcomes occurred, negative
    feelings emerge
  • Families made the right decision but insufficient
    respect for their loss

Disenfranchised Grief (Doka, 1989)Grief Which
is Not Openly Acknowledged or Publicly Mourned
Normal Bereavement Ritual Religion/Spirituality Family Friends Time Given Cards, Flowers, Food Remembrance Reduction Decisions Made in Isolation Not discussed with even closest family Judgment from others No time allotted Secrecy of remembrance
IN Conclusion
  • Bereavement support groups are lacking
  • Much work to be done on ethics related to
    multifetal gestation
  • Committee at ACOG
  • Increase in multiple gestation and prematurity
  • Preimplanation genetic diagnosis
  • What is a nurse to do?

Cultural Implications of Female Genital
  • Practiced in male-dominated societies
  • Patriarchal authority
  • Control of womens bodies
  • Control of fertility
  • Done between 5 and 12 years of age
  • 200,000 women in the US
  • 130 Million women worldwide

Normal Anatomy
  • Normal female genitalia with clitoris, labia
    minora and labia majora intact

Type 2
  • Type 2 FGM is the form of female circumcision
    most commonly seen.It involves excision of the
    clitoris with partial or total excision of the
    labia minora. The tissue is joined in the midline
    above, or just over urethra.A Type 2
    presentation can be quite subtle and may be
    missed by some practitioners when undertaking an
    examination.There may be general or
    peri-urethral scarring or nerve damage, which
    makes penetrative procedures uncomfortable.

Type 3 FGM
  • Type 3 FGM is the most extreme presentation. It
    involves excision of part or all of the external
    genitalia and stitching/ narrowing of the vaginal
    opening. Infibulation - there will be obvious
    anterior midline scar tissue.The infibulation
    may obscure underlying dermatological problems
    such as abscesses, dermoid and sebaceous cysts,
    and other scarring. It may predispose to both
    short and long term health consequences for
    women.In Type 3 FGM, the extent to which
    genital tissue has been removed, varies with the

  • Deinfibulation Labour
  • When undertaking a deinfibulation in labour, the
    steps are the same as for the elective
    procedure.Some adjustment is required to
    compensate for the distension of the perineum as
    the baby's head descends.Provide an explanation
    of the procedure to the woman and elicit her
    co-operation as you work between and during

  • If possible, administer a local anaesthetic along
    the anterior scar tissue.Place 1 or 2 fingers
    underneath and to your left of the anterior scar
    tissue.Infiltrate the scar using a very
    superficial angle on the needle to protect both
    the baby's head and yourself.

  • Use 1 or 2 fingers to create clearance from the
    emerging head prior to inserting the
    scissors.Make the anterior incision up the
    midline scar to just above the urethral meatus

  • The raw edges will retract and the head will
    begin crowning.Check that the perineal area is
    stretching adequately.Note that post infective
    vaginal scarring from the original infibulation ,
    and fibrous tissue of the anterior scar may not
    stretch under pressure.

CXs of FGM
  • Fistulas
  • Leave women incontinent
  • Fixable for about 450
  • What else?
  • Dont be shocked, ask her story

In Utero Surgery
  • The picture is that of a 21-week-old unborn baby
    named Samuel Alexander Armas, who is being
    operated on by surgeon named Joseph Bruner.The
    baby was diagnosed with spina bifida and would
    not survive if removed from his mother's womb.
    Little Samuel's mother, Julie Armas, is an
    obstetrics nurse in Atlanta . She knew of
    Bruner's remarkable Surgical procedure.
    Practicing at Vanderbilt Univ Med Ctr in
    Nashville, he performs these special operations
    while the baby is still in the womb.During the
    procedure, the doctor removes the uterus via
    C-section and makes a small incision to operate
    on the baby. As Dr Bruner completed the surgery
    on Samuel, the little guy reached his tiny, but
    fully developed hand through the incision and
    firmly grasped the surgeon's finger. Dr Bruner
    was reported as saying that when his finger was
    grasped, it was the most emotional moment of his
    life, and that for an instant during the
    procedure he was just frozen, totally immobile.
    The photograph captures this amazing event with
    perfect clarity The editors titled the picture,
    'Hand of Hope.' The text explaining the picture
    begins, 'The tiny hand of 21-week-old fetus
    Samuel Alexander Armas emerges from the mother's
    uterus to grasp the finger of Dr Joseph Bruner as
    if thanking the doctor for the gift of life.'
    Little Samuel's mother said they 'wept for
    days' when they saw the picture. She said, 'The
    photo reminds us pregnancy isn't about disability
    or an illness, it's about a little person.
    'Samuel was born in perfect health, the operation
    100 percent successful.

Hand of Hope
(No Transcript)
  • 31 of women report physical or sexual assault by
    an intimate partner during their lifetime
    (Family violence Prevention Fund, 2008)
  • Health related costs of domestic abuse to
    society, estimated at 4.1 billion (Brackley,

Domestic Abuse Affects Health Care System in
Multiple Ways
  • Increased use by victims and witnesses
  • Children exposed to violence in the home are more
    likely to develop physical and behavior health
  • Women who are domestic abuse victims are more
    likely to engage in negative health behaviors.

Importance of Screening
  • Nurse concerns time to perform screen, as
    important as other nursing assessments, fear of
    offending client, being able to respond to a
    victim, help with referrals.

Other Issues
  • ART
  • Abortion
  • Maternal-Fetal Conflict until fairly recently,
    the fetus was viewed legally as a nonperson.
  • Mother and fetus were viewed as one complex
    client-the pregnant woman.
  • Fetus increasingly viewed as a client separate
    from the mother.

Focus intensified
  • 2002, when George Bush announced that unborn
    children would qualify for government healthcare
    benefits. More designed to promote prenatal
    care, but represented the first time U.S. federal
    policy had defined childhood as starting at

AI,ART and Surrogate Childbearing
  • Legal problems with AI (TI) using donor sperm
  • Donor must sign a form waiving all parental
  • Husbands sign a form agreeing to insemination and
    to assume parental responsibility for the child.
  • ART/IVF guidelines to limit of embryos
    transferred, ethical dilemma of what to do with
    unused embryos? surplus fertilized oocytes? To
    whom do the frozen embryos belong? Parents
    together or separately? The hospital or
    infertility clinic? Who is liable if a woman or
    her offspring contracts HIV disease from a
    donated sperm? Should children be told the method
    of their conception?

Denver Stem Cell Bank
  • 3 hospitals participate

Maternal Newborn Nurses
  • APNs CNMs, NNPs
  • CNS
  • Standards for Professional Nursing Practice in
    the Care of Women and Newborns
  • Infection Protection