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CSM Maternity Nursing
Lecture 1
I.
Intro to Maternity Nursing
A.
Role of the Perinatal Nurse
I.
The Registered Nurse
II.
a.
Scope of nursing practice determined by:
-Calif State Nursing Practice Act-BRN
-Community standards
-Policy and Procedure of facility
-JCAHO-Joint Commission on Accreditation
of Healthcare Organizations
-Dept. of Health Services
b.
Nurses held legally responsible for practicing
within scope of practice
c.
Specialty Organization: AWHONN
-Association of Women’s Health,
Obstetrics, and Neonatal Nurses
d.
Orientation Period/Specialization
-Labor and Delivery
-Nursery/Level II Nsy/NICU
-Postpartum/Mother-Baby-↑ since 1990’s
-Occasional problems with
comprehensive care-territorial
-Differences in opinions lead to pt
confusion
Expanding roles in Perinatal Nurses
a.
Nurse Practitioners
-Defined by ANA as: provide
comprehensive health assessments,
determine diagnoses
plan/prescribe treatment/medications
manage healthcare regimens
for the individual, families, and the
community
-In 1960’s, shortage of MD’s lead to
creation of the RNP
-May provide family care or specialize
-May work independently in > 20 states
-Take part in a certificate program or
Master’s Degree program
-Requires documentation of continued
education and practice
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b.
Clinical Nurse Specialists
-Defined by ANA: Clinical expert who
provides direct pt care services
--health assessments
--health promotion
--preventative interventions
-MSN
-Expertise in planning, supervising, and
delivery of nursing care to families in
childbearing period
-Case managers
-Consultant
-Family and staff educator
-Coordination of delivery of nursing care
to families requiring intensive nursing
support
-Research activities/articles
-May work specifically with high risk pts
-Traditionally worked in hospitals but now
found in nursing homes, schools, home
care settings and hospice.
c.
Certified Nurse Midwife
-Defined by ACNM: independent
management of women’s health
care especially R/T pregnancy,
childbirth, PP period, and care of the
newborn
-Graduate from a certificate or MSN
program
-Also provide family planning services,
other gynecological needs, and peri/
postmenopausal care
-One of the oldest professions
-1925-Mary Breckenridge establishes
Frontier Nursing Services-first NurseMidwife to practice in the US
-American College of Nurse Midwives
was incorporated in 1955
-provide care to women with low
incomes, uninsured, and minorities who
don’t seek out regular health care
-lower rates of cesarean sections in
facilities where CNM’s practice
d.
Certified Nurse Anesthetists
-Defined by AANA: provide
--pre-anesthetic assessment
--develop and implement plan
of care
--perform general, regional, local,
and sedative anesthesia
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--manage pt’s airway/pulmonary
status
--facilitate emergence/recovery from
anesthesia
--provide follow-up evaluation and care
--respond to emergency situations
to asst with ACLS, airway, medications
-Minimum 24 month programs/MSN with
--45 hrs professional aspects
--135 hrs anatomy/physiology/
pathophysiology
--45 hrs chemistry
--90 hrs anesthetic principles
--45 hrs clinical/literature review
--knowledge of at least 450 anesthetics
-80 % practice in an anesthesia care team
-20 % practice independent at solo
providers
e.
B.
Nurse Consultants
-experts in a specific area of nursing
-fee for service
-may act as expert witnesses
-used by corporations R/T developing
products/equipment
-consult to texts, electronic media, and
periodicals
Legal and Ethical Issues
I.
Litigious nature of this specialty
a.
↑ number of malpractice cases involving
childbirth issues
-OB/Gyn cases 2nd only to surgeries
b.
Minimum standard of care:
-care that a reasonable, prudent nurse would
provide in the same or similar circumstances
c.
Predominant theory of Liability-negligence
-4 elements
duty exists
breech of duty-standard of care violated
injury
connection between violation of the
standard and the injury
d.
Malpractice lawsuits are based on the
assumption that the health care provider
failed to meet the professional standard of
care and resulted in injury
e.
Alleged injury to fetus, neonate, or mother
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II.
f.
Families expecting a healthy child-bad
outcome means mistake must have been
made
g.
Attribute problem to one or more members
of the health care team
-frequent unavailability of physician
-time frame to communicate may be short
h.
To support expert opinion, need evidence:
-hospital procedures
-nursing policies
-guidelines established by professional
organizations
-state nurse practice acts
-JCAHO
Informed Consent
a.
Process by which a pt decides to have a
certain medical or surgical procedure
-includes knowing and understanding
what health care treatment is being
undertaken
b.
More than just signing a form
c.
Process by which the physician, nurse, and
possibly other health care professionals convey
to pt the information for them to decide whether
or not to proceed with the course of tx
d.
Without proper consent, provider could be the
subject of a lawsuit alleging assault, battery,
negligence , or a combination of actions
f.
types of consent:
-expressed-oral or written
-implied: nurse states here to draw blood
and the pt extends her arm
--may be used in emergency cases
--when pt continues to take tx without
objection
--during surgery, additional surgery is
indicated
g.
Informed refusal
-can take place at initiation of tx or any time
after start of tx
-refusal is valid even after informed consent is
given
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-refusal must be voluntary, uncoerced, and not
made under fraudulent circumstances
-pt must refuse tx with knowledge and
understanding of the refusal
-chart should include signed refusal form by pt
and nursing notes should include time
left, left with whom, risks and
consequences of no further tx, and
who will be notified
III.
IV.
Common Legal Pitfalls
a.
#1 allegation: birth of neurologically-impaired infant
b.
reporting/recording errors:
-incomplete initial H & P
-failure to observe & take appropriate action
-failure to communicate changes in a pt’s
condition in a timely manner
-incomplete and/or inadequate documentation
-failure to use or interpret fetal monitoring
appropriately
-inappropriate pitocin monitoring/usage
-improper sponge/instrument count
c.
almost ¾ of OB/Gyn’s have been sued
-most cases will not go trial but be settled
out of court
d.
30% have had 3 or more law suits
e.
rising costs of liability insurance
f.
↑ demands for accountability created by
expanding the scope of practices
g.
cost containments
-shorter hospital stays
-use of unlicensed asst personnel
-decrease in hospital staff
h.
changes in technology mean needed
continued education: EFM
Standards of Care
a.
Standardized procedures/policies
b.
supervision of unlicensed asst. personnel
KNOW your facility’s Scope of Practice
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VI.
Ethical Dilemmas Unique to Perinatal Nursing
a.
fetal research-laws vary by state
b.
fetal surgery
-i.e.: bilateral hydronephrosis, congenital
diaphragmatic hernia
-what if mother refuses tx
c.
abortion-Roe vs. Wade (1973)
-morning-after pill
Plan B-levonorgestrel
-lack of estrogen ↓ nausea
-medical abortion
US: mifepristone + misoprostol
France: RU-486
d.
artificial insemination
-AIH-husband’s sperm-problem with
mother
-AID-donor sperm
-legal problems-donor relinquishes rights
e.
surrogate childbirth
-buying a child-$$$$
-biological mother may refuse to give up
the newborn
f.
ART-Asst. Reproductive Technology
-IVF-ET
-GIFT, ZIFT
g.
embryonic stem cell research/cord blood banking
h.
The Neonate
-iatrogenic procedures
prolonged use of ventilators
O2 therapy
-problem: should we save the lives of infants
only to have them lead lives of pain,
disability, and deprivation?
-who decides if major intervention is used
-what kind of care do you give or deny the
infant to allow him to die with dignity
and comfort
i.
The Mother
-use life support in irreversible conditions?
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V.
C.
Nursing Role
a.
Communication
-interactions between MD’s, CNM’s, &
nurses
-was a clear line of communication used
-was the chain of command followed
-was there informed consent
-the better the communication between
nurse and pt, less use of litigation
-earlier discharges home mean more
educational responsibilities for the
RN
b.
Use of EFM
-first introduced at Yale University in 1958
-In last 50 yrs of use, no ↓ in rate of CP
-is partially responsible for ↑ in C/S rate
-ordinary part of Intrapartum careconstant threat of legal action
Review of Conception/Fetal Development
01/16
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