Obstetric Nurse Care
Obstetric nursing is the specialty dealing with the care of a woman and her offspring during pregnancy, childbirth and the puerperium. This field of nursing is often further specialized into Perinatal Nursing and Labor & Delivery Nursing. Modern day obstetric nurse care begins with the antenatal care which is vital for satisfactory perinatal outcomes. Obstetric nurses also need to identify high risk factors like pre-eclampsia, abnormal placentation or abnormal fetal presentation and give suitable interventions. This includes routine physical examinations and routine laboratory tests like complete blood count, blood grouping, Pap smear ,HIV screen in the first trimester, MSAFP/triple screen , ultrasound , amniocentesis in the second trimester, hematocrit and glucose loading test in the third trimester. Obstetric nursing is a high risk role that requires core competence (Kowalski et.al, 1995). Intrapartum emergencies are challenging to all perinatal nurses because of the increased risk of adverse outcomes for the mother and foetus (Curran, 2003).
Problems in Obstetric Nurse Care
An obstetric nurse today is under pressure to provide care with enhanced threats of litigations coupled with time and economic restraints (Martell, 2006). Recent research studies indicate that using evidence-based practice improves birth outcomes (Edgren, 2001). Complications during pregnancy includes routine problems like back pain, constipation, contractions, dehydration, edema, gasteroesophageal reflux disease, hemorrhoids, pica, lower abdominal pain, increased urinary frequency, varicose veins and serious complications like ectopic pregnancy, pelvic girdle pain and placental abruption. Situations that call for obstetric nursing interventions during labor include monitoring the progress of labor, reviewing the nursing chart, performing vaginal examinations, assessing the cardiotocograph, infusion oxytocin, providing pain relief, surgical assistance by forceps or ventouse and caesarean section. Emergency situations that call for obstetric nursing interventions include ectopic pregnancy and pre-eclampsia. Severe pre-eclampsia can have a catastrophic effect on maternal-fetal outcome and hence, obstetric nurses should have the knowledge of related pathophysiologic processes to give appropriate interventions (Surratt, 1993).
Pregnant women with cardiac complications present a unique challenge in the sense that the physiologic adaptations that accompany pregnancy and labor predispose the woman with cardiac complications to cardiac decompensation (Witcher and Harvey,2006).Preterm premature rupture of the membranes occurs when the amniotic membrane rupture occurs prior to the completion of the 36th week of gestation and causes preterm deliveries. Expectant management is the current standard of care in mothers diagnosed with PPROM without evidence of infection, active labor, or fetal compromise. Expectant management is the prolongation of the pregnancy to increase fetal gestational age .Nursing interventions and assessments in such case include preterm labor, side effects of tocolytic therapy, maternal infection, fetal infection, fetal compromise, side effects of extended bed rest, maternal stress, educational needs, and routine prenatal care (Stringer et.al, 2004).Deep vein thrombosis (DVT) in pregnancy is a rare but serious complication (Brochu, 2004). Risk factors include prolonged bed rest or immobility, pelvic or leg trauma, and obesity. Additional risk factors are preeclampsia, cesarean section, instrument-assisted delivery, hemorrhage, multiparity, varicose veins, a previous history of a thromboembolic event and hereditary or acquired thrombophilias. Low molecular weight heparin is the anticoagulant of choice to treat active thromboembolic disease or to administer for thromboprophylaxis (Brochu, 2004). Perinatal emergencies, such as seizures, amniotic fluid embolus, hemorrhage, and uterine rupture demand intrinsic survival techniques. During hypovolemic events, the pregnant uterus becomes a vital source of blood volume and fetal hypoxemia can stress the fetus into initiating labor (Curran, 2003).
Magnesium sulfate is commonly used in obstetrical practice both for seizure prophylaxis in preeclampsia women and to inhibit preterm labor contractions. Intravenous magnesium sulfate treatment is a routine practice in obstetrics .But the administration of magnesium sulfate occasionally results in accidental overdose and patient harm. Implementation of the vigilance and dose recommendations decrease the likelihood of an accidental overdose (Simpson, 2004). Urinary tract infection causes serious consequences if it occurs during the course of a woman's pregnancy and if untreated leads to pyelonephritis, preterm labor, or Group B Streptococcal infection in the newborn. Early detection and prompt treatment of urinary tract infections in pregnancy reduces complications. (Morgan, 2004). Adverse outcomes related to care during the second stage of labor are significant factors of obstetric complications. Obstetric nurses can practice a safe second stage care at the bedside, assisting women during pushing efforts and monitoring maternal-fetal status. The FHR pattern is an important indicator to assess fetal response to the second stage labor (Simpson, 2004).Thus, monitoring the preterm fetus during labor is an important obstetric responsibility. A study to assess the frequency with which auscultation could be used as the primary mode of fetal assessment during labor in a busy labor and delivery has shown that auscultation with stringent evaluation and recording frequency is not feasible under normal labor and delivery room conditions unless 1:1 nursing care is always available (Morrison et.al, 1993). Enough attention should be drawn to FHR monitoring during preterm labor (Simpson, 2004). There are several languages for electronic fetal monitoring (EFM) and includes those described in the Association of Women's Health, Obstetric and Neonatal Nurses Fetal Heart Monitoring Principles and Practices text( Feinstein, Torgersen and Atterbury, 2003 ), the American College of Obstetricians and Gynecologists Technical Bulletin Fetal Heart Rate Patterns: Monitoring, Interpretation and Management( ACOG, 1995 ) and the National Institute of Child Health and Human Development Research Planning Workshop ( NICHD, 1997 and Simpson, 2004).
Obstetric Nurse Role in Care
Patient care problems in obstetric nursing includes a lack of continuity of care for obstetric patients, inadequate prenatal instruction and the unpredictability of patient census in the labor and delivery area (Kowalski et.al, 1977). The Social Representation Theory is seen as a useful framework to study the evolution of obstetrics nursing (Riesco, 1998). A retrospective cohort study to examine if nurse care reduces the risk of cesarean delivery has demonstrated that labor abnormalities and diagnosis of fetal distress are less frequent in patients cared for by nurses and there is an association with a lower incidence of cesarean section (Butler et.al, 1993). A recent research study to evaluate the effect of change of shift for nurses on complications associated with cesarean delivery has established that cesarean delivery during nursing change of shift is associated with increased risk of neonatal facial nerve palsy (Bailit et.al, 2008). Maternal-fetal assessment, management of oxytocin infusions and second-stage care are the three areas where nurses have primary responsibility. Effective obstetric nurse care and interventions in these areas have been shown to promote maternal-fetal well-being, minimize risk, and enhance patient safety (Simpson, 2005). A hermeneutic inquiry exploratory study to develop new understandings of what it means to women in labor for a nurse to be present during childbirth has shown that a nurse's presence was a very important part of their childbirth experience (MacKinnon ,2005).
Obstetric nursing is a high risk role that requires core competence. Adverse outcomes related to care during the second stage of labor are significant factors of obstetric complications. Effective obstetric nurse care and interventions have been shown to promote maternal-fetal well-being, minimize risk, and enhance patient safety.
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Charles L. Berman
Liz Di Bernardo