CHAPTER 1.

A FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING

I. Goals and Philosophies of Maternal and Child Health Nursing

Obstetrics, or the care of women during childbirth

 is derived from the Greek word obstare, which means “to keep watch.”

Pediatrics
 is a word derived from the Greek word pais, meaning “child.”

NOTE: The care of childbearing and childrearing families is a major focus of nursing practice,
because to have healthy adults you must have healthy children. To have healthy children, it
is important to promote the health of the childbearing woman and her family from the time
before children are born until they reach adulthood.

PRIMARY GOAL: Stated simply as the promotion and maintenance of optimal family health
to ensure cycles of optimal childbearing and childrearing.
THE RANGE OF PRACTICE INCLUDES:
• Preconceptual health care
• Care of women during three trimesters of pregnancy and the puerperium (the 6 weeks
after childbirth, sometimes termed the fourth trimester of pregnancy
Care of infants during the perinatal period (6 weeks before conception to 6 weeks after
birth) • Care of children from birth through adolescence
• Care in settings as varied as the birthing room, the pediatric intensive care unit, and the
home
II. STANDARDS OF MATERNAL AND CHILD HEALTH NURSING PRACTICE
III. A FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING CARE\
 A framework can be visualized within a framework in which nurses, using nuring
process, nursing theory, and evidence-based practice, care for families during
childbearing and childrearing years through four phases of health care:
• Health promotion
• Health maintenance
• Health restoration
• Health rehabilitation

1. Nursing Process
 Is a form of problem solving based on the scientific method
 Serve as the basis for assessing, making a nursing diagnosis, planning, organizing, and
evaluating care
 Is applicable to all health care settings, from the prenatal clinic to the pediatric intensive
care unit.
 Is proof that the method is broad enough to serve as the basis for nursing care

2. Evidence-Based Practice
 Is the conscientious, explicit, and judicious use of current best evidence in making
decisions about the care of patients (Foxcroft & Cole, 2009).
 Evidence can be a combination of research, clinical expertise, and patient preferences
when all three combine in decision making. The worth of evidence is ranked according
to:
• Level I: Evidence obtained from at least one properly designed randomized controlled
trial.
• Level II: Evidence obtained from well-designed controlled trials without
randomization, well-designed cohort or case-control analytic studies, or multiple time
 series with or without an intervention. Evidence obtained from dramatic results in
uncontrolled trials might also be regarded as this type of evidence.
• Level III: Opinions of respected authorities, based on clinical experience, descriptive
studies, or reports of expert committees (U.S. Preventive Services Task Force, 2005).

 Use of evidence-based practice helps to move all health care actions to a more solid,
and therefore safer, scientific base.
 The Cochrane Database of Systematic Reviews is good source for discovering evidence-
based practices as the organization consistently reviews, evaluates, and reports the
strength of health-related research.

3. Nursing Research
 the controlled investigation of problems that have implications for nursing practice,
provides evidence for practice and justification for implementing activities for outcome
achievement, ultimately resulting in improved and cost-effective patient care.
 Some examples of current questions that warrant nursing investigation in the area of
maternal and child health nursing include the following:
• What is the most effective stimulus to encourage women to come for prenatal care or
parents to bring children for health maintenance care?
• How much self-care should young children be expected (or encouraged) to provide
during an illness?
• What is the effect of market-driven health care on the quality of maternal-child
nursing care?
• What active measures can nurses take to reduce the incidence of child or intimate
partner abuse?
• How can nurses best help families cope with the stress of long-term illness?
• How can nurses help prevent violence such as homicide in communities and modify
the effects of violence on families?
• What do maternal-child health nurses need to know about alternative therapies such
as herbal remedies to keep their practices current?

4. Nursing Theory
 Nursing theorists offer helpful ways to view clients so that nursing activities can best
meet client needs—for example, by seeing a pregnant woman not simply as a physical
form but as a dynamic force with important psychosocial needs, or by viewing children
as extensions or active members of a family as well as independent beings.
 Another issue most nursing theorists address is how nurses should be viewed or what
the goals of nursing care should be.

IV. A CHANGING DISCIPLINE

1. National Health Goals

 In 1979, the U.S. Public Health Service first formulated health care objectives. These
goals are ongoing and modified every 10 years (http://www.nih.gov).
 Two overarching national goals are to:
(a) increase quality and years of healthy life and
(b) eliminate health disparities.
2. Trends in the Maternal and Child Health Nursing Population

Client advocacy is safeguarding and advancing the interests of clients and their families. The
role includes knowing the health care services available in a community, establishing a
relationship with families, and helping them make informed choices about what course of action
or service would be best for them.

3. Measuring Maternal and Child Health

 Is not as simple as defining a client as ill or well because individual clients and health
care practitioners may have different perspectives on illness and wellness.

a. Birth Rate
b. Fertility Rate - reflects what proportion of women who could have babies are having
them. Fertility rates may be low in countries troubled by famine, war, or disease
c. Fetal Death Rate - defined as the death in utero of a child (fetus) weighing 500 g or
more, roughly the weight of a fetus of 20 weeks’ or more pregnancy. Fetal deaths
may occur because of maternal factors such as maternal disease, premature cervical
dilation, or maternal malnutrition or fetal factors such as fetal disease, chromosome
abnormality, or poor placental attachment.
d. Neonatal Death Rate - The first 28 days of life are known as the neonatal period,
and an infant during this time is known as a neonate. The neonatal death rate
reflects not only the quality of care available to women during pregnancy and
 childbirth but also the quality of care available to infants during the first month of
life.
e. Perinatal Death Rate - is the time period beginning when a fetus reaches 500 g
(about week 20 of pregnancy) and ending about 4 to 6 weeks after birth. The
perinatal death rate is the sum of the fetal and neonatal rates.
f. Infant Mortality Rate - is an index of its general health because it measures the
quality of pregnancy care, nutrition, and sanitation as well as infant health. This rate
is the traditional standard used to compare the health care of a nation with that of
previous years or of other countries.
g. Maternal Mortality Rate - is the number of maternal deaths that occur as a direct
result of the reproductive process per 100,000 live births.
h. Childhood Mortality Rate
i. Childhood Morbidity Rate

4. Trends in Health Care Environment

a. Initiating Cost Containment

 Cost containment refers to systems of health care delivery that focus on reducing the
cost of health care by closely monitoring the cost of personnel, use and brands of
supplies, length of hospital stays, number of procedures carried out, and number of
referrals requested while maintaining quality care (Callens, Volbragt, & Nys, 2007).

b. Increasing Alternative Settings and Styles for Health Care

c. Including the Family in Health Care
 d. Increasing the Number of Intensive Care Units
e. Regionalizing intensive Care
f. Increasing Comprehensive and Collaborative Care settings
g. Increasing Use of Alternative Treatment Modalities
h. Increasing use of Technology
i. Freebirthing g refers to women giving birth without any health care provider supervision
(Cooper & Clarke, 2008).

5. Health Care Concerns and Attitudes

a. Increasing Emphasis on Preventive Care
b. Increasing Concern for the Quality of Life
c. Increasing Awareness of the Individuality of Clients
d. Empowerment of Health Care Consumers

V. ADVANCED-PRACTICE ROLES FOR NURSES IN MATERNAL AND CHILD HEATH

1. Clinical Nurse Specialist

 are nurses prepared at the master’s or doctorate degree level who are capable of acting
as consultants in their area of expertise, as well as serving as role models, researchers,
and teachers of quality nursing care.
 Examples of areas of specialization are neonatal, maternal, child, and adolescent health
care; genetics; childbirth education; and lactation consultation (McArthur & Flynn,
2008).

2. Case Manager
 is a graduate-level nurse who supervises a group of patients from the time they enter a
health care setting until they are discharged from the setting or, in a seamless care
system, into their homes as well, monitoring the effectiveness, cost, and satisfaction of
their health care.
 They help prevent fragmentation of care and ensure that such important qualities as
continuity of care and providing a feeling of “medical home” are included in care.

3. Nurse Practitioner
 are nurses educated at the master’s or doctoral level.
 Recent advances in technology, research, and knowledge have amplified the need for
longer and more in depth education for nurse practitioners as they play pivotal roles in
today’s health care system

4. Women’s Health Nurse Practitioner

 has advanced study in the promotion of health and prevention of illness in women.
 Such a nurse plays a vital role in educating women about their bodies and sharing with
them methods to prevent illness; in addition, they care for women with illnesses such as
 sexually transmitted infections, and offer information and counsel them about
reproductive life planning.
 They play a large role in helping women remain well so that they can enter a pregnancy
in good health and maintain their health throughout life.
5. Pediatric Nurse Practitioner (PNP)
 is a nurse prepared with extensive skills in physical assessment, interviewing, and well-
child counseling and care.
 In this role, a nurse interviews parents as part of an extensive health history and
performs a physical assessment of the child

6. Neonatal Nurse Practitioner (NNP)

 is an advanced-practice role for nurses who are skilled in the care of newborns, both
well and ill. NNPs may work in level 1, level 2, or level 3 newborn nurseries, neonatal
follow-up clinics, or physician groups.
 The NNP’s responsibilities include managing and caring for newborns in intensive care
units, conducting normal newborn assessments and physical examinations, and
providing high-risk follow-up discharge planning (Bowen, 2007).
 They also are responsible for transporting ill infants to these different care settings.

7. Family Nurse Practitioner (FNP)

 is an advanced-practice role that provides health care not only to women and children
but also to the family as a whole. In conjunction with a physician, an FNP can provide
prenatal care for a woman with an uncomplicated pregnancy.
 The FNP takes the health and pregnancy history, performs physical and obstetric
examinations, orders appropriate diagnostic and laboratory tests, and plans continued
care throughout the pregnancy and for the family afterward.
 FNPs then monitor the family indefinitely to promote health and optimal family
functioning during health and illness.

8. Certified Nurse-Midwife (CNM)

 is an individual educated in the two disciplines of nursing and midwifery and licensed
according to the requirements of the American College of Nurse-Midwives (ACNM) who
plays an important role in assisting women with pregnancy and childbearing

VI. LEGAL CONSIDERATIONS OF MATERNAL-CHILD PRACTICE

Nurses are legally responsible for protecting the rights of their clients, including
confidentiality, and are accountable for the quality of their individual nursing care and
that of other health care team members.

Documentation is essential for protecting a nurse and justifying his or her actions. This
concern is long-lasting, because children who feel they were wronged by health care
personnel can bring a lawsuit at the time they reach legal age. This means that a nursing
note written today may need to be defended as many as 21 years into the future.
VII. ETHICAL CONSIDERATIONS OF PRACTICE
Some of the most difficult ethical quandaries in health care today are those that involve
children and their families. Examples are
• Conception issues, especially those related to in vitro fertilization, embryo transfer,
ownership of frozen oocytes or sperm, cloning, stem cell research, and surrogate mothers
• Abortion, particularly partial-birth abortions
• Fetal rights versus rights of the mother
• Use of fetal tissue for research
• Resuscitation (for how long should it be continued?)
• Number of procedures or degree of pain that a child should be asked to endure to achieve
a degree of better health
• Balance between modern technology and quality of life