Current Issues in Maternal-Newborn Nursing:

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Current Issues in Maternal-Newborn Nursing

• No More Octamom!

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What Are Current Issues in Maternal-Newborn
Nursing?
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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
  International)
• 37th (Lancet)
• An American woman is at least twice as likely to
  die in pregnancy or childbirth as a woman in much
  of Europe.

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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

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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

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jhpiego

• Hemorrhage 1 cause of maternal death
• Community based distribution of misoprostol
• 3 little pills after you deliver the baby
• http//www.npr.org/templates/story/story.php?story
  Id130180983scemaf
• 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.

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Be the change that you want to be in the
world. Gandhi

• Its Global
• One woman dies every minute from a pregnancy
  complication
• 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
  women

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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

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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
  OB
• Education and simulation drills.

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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.

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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

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Infant Mortality

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

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Power of Nurses

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

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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

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B4Babies

• 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

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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

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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

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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).

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Where We Need to Be

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

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WHY?

• Among the myriad possible explanations for the
  increase
• 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
  singleton
• 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

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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

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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

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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

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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.

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MDGs

• 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.

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Social Issues Affecting Women in Poverty

• Divorce
• Lower wages compared with men
• Public assistance
• Homelessness

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Two thirds of Americans living in poverty are
women and children
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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

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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

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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

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Lily Ledbetter Act
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Causes of Wage Gap

• Deliberate wage discrimination against women
• Undervaluing of womens work
• Womens socialization

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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
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Some mothers are able to combine professional
careers with motherhood by telecommuting from a
home office.
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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

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Childhood education centers provide preschoolers
with advanced skills for early education and
provide care while parents work outside of the
home
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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
  exchange
• US according to your effort, free market
  exchange, can buy ART

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What Happened at Kaiser Bellflower A just
thing???

• Walkin no clue where she came from
• Anticipated 7 got 8
• Had staff of 46 present for scheduled c/s
  (volunteer)
• 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

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Justice?

• 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
  embyos.

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Regulation in Response to Cochrane

• Canada
• England
• Sweden
• One Embryo, One Birth (Karlstrom and Bergh,
  2007)

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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
  singletons
• Nadia Suleman, a woman under 35 received six
  embryos transferred.

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Reduction

• 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

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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
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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?

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FGM
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Cultural Implications of Female Genital
Mutilation

• 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

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FGM
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Normal Anatomy

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

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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.

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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
  individual.

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Labour

• 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
  contractions

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Deinfibulation

• 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.

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Excision

• 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

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Birth

• 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.

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Repair
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CXs of FGM

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

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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.

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Hand of Hope
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(No Transcript)
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Violence
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Violence

• 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,
  2008)

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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
  problems
• Women who are domestic abuse victims are more
  likely to engage in negative health behaviors.

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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.

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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.

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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
  conception.

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AI,ART and Surrogate Childbearing

• Legal problems with AI (TI) using donor sperm
• Donor must sign a form waiving all parental
  rights.
• 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?

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Denver Stem Cell Bank

• 3 hospitals participate

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Maternal Newborn Nurses

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