Nursing Strategies for Perinatal Care

A pregnancy has the potential to raise many emotions and questions. What’s going to happen to her body? Will anything go medically wrong? The healthcare team is often one of the only sources of information that the pregnant woman will consult with such questions. Because the prenatal and perinatal periods are a critical time in preserving healthy mother and child outcomes, nurses have a crucial role in providing emotional, medical, and educational support to their obstetric patients.
Strategies that nurses can use to provide such support include encouraging pregnant women who statistically do not receive prenatal care to seek care through avenues such as social services and other community organizations, identifying high-risk mothers as soon as possible in the pregnancy so that interventions may be made in time to avoid adverse outcomes, and functioning as a labor coach for women who come to the hospital without a support partner and/or childbirth education. In 2005, there were over four million births in the United States, as recorded by the CDC (Martin et al, 2005). Many of these women may have had little or no prenatal care, which correlates with higher neonatal care unit (NICU) admission rates (Stankaitis, Brill, & Walker, 2007). A lack of prenatal care can lead to many other adverse health outcomes, including low birth weight babies, mother-child transmission of various diseases, and complications of drug addiction, diabetes, and other disease processes. In fact, babies born to mothers who received no prenatal care are three times more likely to be born at low birth weight, and five times more likely to die, than those whose mothers received prenatal care (Health Resources & Services Administration, 2008).
One strategy that nurses can use to enhance maternal-child outcomes is to facilitate the use of prenatal care for those women who do not often receive complete care. These include women of low socioeconomic status, as well as women of color. One study of low-income African-Americans in Florida showed that prenatal care was begun in the first trimester for only 50% of the population in Brevard County. When this percentage was increased via a nurse-led social service program that focused on culturally competent care, the number of low birth-weight infants decreased by 33% (Browne-Krimsley, 2004). In another study, the number of Medicaid-dependent pregnant women who delivered babies admitted to the NICU was vastly decreased by the use of a nurse-coordinated program called Healthy Beginnings. In Healthy Beginnings, the nurse employs outreach workers to provide home health prenatal care and other social services to women of low socioeconomic status (Stankaitis, Brill, & Walker, 2007). The nurse plays a crucial role in opening the door to prenatal care during the critical first trimester, as well as following up throughout the pregnancy.
In addition to facilitating prenatal care for those who do not usually seek it out, the nurse should endeavor to identify high-risk mothers early in the prenatal period so as to administer interventions to avoid adverse maternal-child outcomes. Brenna L. Anderson (2004) showed that the rate of human immunodeficiency virus screening during pregnancy was increased by the use of a trained nurse educator. Without the nurse educator, many women refused the screening process, which interfered with the ability of the medical team to provide zidovudine during pregnancy to avoid mother-child transmission of the disease. In another project, Dr. Yvonne Hauck (2007) worked with community health nurses to develop better mental health services for mentally ill pregnant women. The project focused on factors that the women could plan to change, including appointment attendance, smoking cessation, and nutritional advice. Mentally ill women often do not comply with prenatal care advice, or stop taking their medications, which can adversely affect the fetus. The project is currently in progress, and the staff are optimistic about the outcomes.
Along with nurse-mediated prenatal care, nurses are crucial to the actual birth experience as labor coaches. Many women do not take advantage of childbirth education during their pregnancy, or do not have family or friends to help them during labor. In these cases, nurses must function as the labor coach to promote healthy outcomes for mother and child. One study showed that continuous labor support provided by a nurse present throughout the birth process correlated to a 7% increase in spontaneous vaginal births as opposed to C-section. “Continuous support patients” had less incidence of C-section, were less likely to request analgesia, and were more satisfied with their experiences (Nicholson, 2007). The reasons for these occurrences is thought to be that patients feel more at ease with trained personnel at hand throughout the labor and more opportunity for nurse-provided education along the way.As the previous studies have shown, nurses are really at the forefront of prenatal and perinatal care, leading to better maternal-child outcomes. Clinics, social services, nurse hotlines, and other resources are even promoted by the insurance companies in the endeavor to avoid costly adverse outcomes in pregnancy and labor. This should lend great anticipation to those nurses with interest in the field.
Obstetrical, labor/delivery, and postpartum nurses are both a necessity and a blessing to the perinatal process when they use strategies such as acting as labor coaches, identifying high-risk mothers early in the prenatal period, and encouraging mothers who statistically do not receive any prenatal care to do so through social and community services.
Intervention #1
Identify high-risk mothers early in the prenatal period so as to administer interventions to avoid adverse maternal-child outcomes.
Disadvantage #1:
One problem that arises with identifying high-risk pregnancies is that women in general often do not find out that they are pregnant until many weeks into the pregnancy, and the first prenatal appointment may not be available until after the window when such interventions should be made. According to Michael Lu in an American Family Physician article, “by the time pregnant women have their first prenatal visit, it may be too late to prevent some placental development problems or birth defects.” Lu also stresses that in early prenatal care, it is often too late to restore allostasis and that pregnant women with under-functioning allostatic systems are more susceptible to pregnancy complications (2007). All women, and especially women at high risk, should seek pre-conception care to avoid these kinds of complications. However, this becomes difficult when a woman does not even know she is pregnant, or is not trying to get pregnant. This is one reason why physicians are stressing that women of child-bearing age should have a high intake of folic acid.
Disadvantage #2:
Another barrier to providing prenatal care for high-risk mothers is that, in many cases, these women refuse prenatal care. This is true in many different classes of women, including poor and rich, young and old, across the ethnic lines. One study that looked at the effectiveness of policies that implement HIV testing for pregnant women found that women older than 30 years of age were less likely to accept the testing (Samquist et al., 2007). Perhaps the reason for this is that these women feel that they are too old to have contracted the disease—they are married or in committed monogamous relationships. Other groups that may refuse prenatal care are the poor and/or uninsured. The rates of uninsured pregnant women are growing every year as the cost of insurance rises. Many of these uninsured women decide that it is too expensive to get prenatal care, and they may feel that it is expendable.
Intervention #2
Nurses can function as the labor coach, giving continuous labor support to promote healthy outcomes for mother and child.
Disadvantage #1:
Continuous labor support is rarely available, related to the cost of staffing and the nursing shortage. A nursing administrator commented on a study promoting continuous labor support by saying that “there isn’t technically such a thing as a continuous caregiver during labour…as far as nurses or midwives or regular hospital staff, it’s very unusual that they can spend the entire time with just one woman in labor” (Nicholson, 2007). Hospitals have the mindset that they can’t afford to staff their birth centers with that kind of personnel load. However, if hospitals reorganize their staffing to cross-train OB nurses and post-partum nurses, this kind of staffing may well be possible.
Disadvantage #2:
Continuous labor support is only as helpful as the one giving the support. Just as there are nurses out there on the med-surg floor that a student would either choose to emulate or choose to use as the example of “what not to do,” there are labor support nurses and/or midwives in those same categories. Some nurses give wonderful labor support, while others merely bark out orders, placations, or blatantly belittle the woman in labor. Imagine the horror for the woman who received a nurse from the latter category for her entire labor! In a study by three midwives,“Care interpreted as unethical was characterized by physical closeness and prescriptions of what had to be experienced and done, or by neglecting the nontechnical aspects of caring related to the birthing woman, the expectant father, the new parents and the newborn baby. Bergstrom and co-workers emphasized the importance of being open to what is happening with a woman ‘rather than to what is supposed to happen according to an outdated and inaccurate script of how labour and birth should proceed.’ “ (Hallgren, Kihlgren, and Olsson, 2005). Nurses who aspire to work in the labor and delivery unit should be prepared to provide continuous labor support, and should undergo specific training for this endeavor. This will aid in providing quality continuous care for every woman, not only those who get the “good nurses.”

References

Anderson, B. (2004). Improving universal prenatal screening for humanimmunodeficiency virus. Infectious Diseases in Obstetrics and Gynecology,12(3/4), 115-120. Retrieved April 17, 2007, from ProQuest database.

Browne-Krimsley, V. (2004). Lessons learned: providing culturally competent care in anurse-managed center. Association of Black Nursing Faculty Journal, 15.4 (July- August 2004), 71-74. Retrieved April 17, 2007, from Expanded Academic ASAP database.

Hallgren, A., Kihlgren, M., and Olsson, P. (2005). Ways of Relating During Child-Birth: An Ethical Responsibility and Challenge for Midwives. Nursing Ethics, 12(6), 606. Retrieved May 9, 2008, from ProQuest database.

Hauck, Y. (2007). Project to improve pregnancy outcomes. Australian NursingJournal, 14,(10), 33. Retrieved January 29, 2008, from ProQuest database.

Health Resources and Services Administration (2008). A Healthy Start: Begin beforebaby is born [WWW document]. Retrieved February 20, 2008.URL http://mchb.hrsa.gov/programs/womeninfants/prenatal.htm

Lu, Michael C. (2007). Recommendations for Preconception Care. American FamilyPhysician, 76 (3), 397. Retrieved May 9, 2008, from ProQuest database.

Martin, J., Hamilton, B., Sutton, P., Ventura, S., Menacker, F., Kirmeyer, S., & Munson,M. (2005). Births: Final Data for 2005. National Vital Statistics Reports, 56 (6).Retrieved January 18, 2008, from general search engine.

Nicholson, P. (2007). Continuous labour support linked to best births, but rarelyavailable. Medical Post, 43(27), 44. Retrieved January 29, 2008, from ProQuestdatabase.

Samquist, C., Cunningham, S., Sullivan, B. (R.N.), & Maldonado, Y. (2007). The Effective-ness of State and National Policy on the Implementation of Perinatal HIVPrevention Interventions. American Journal of Public Health, 97, 6, 1041.Retrieved May 9, 2008, from ProQuest database.

Stankaitis, J., Brill, H., & Walker, D. (2007). Reduction in neonatal intensive care unitadmission rates in a Medicaid managed care program [Electronic version]. American Journal of Managed Care, 11, 166-172.