3.

CONTEMPORARY PERSPECTIVES IN
OBSTETRICS
Tremendous advances have taken place in the care of mothers and their infants during
the post 150 years. Nurses have been critically important in developing strategies to
improve the well being of the women and their infants and have led the efforts to
implement clinical practice guidelines and to practice using evidence based approach.
Today nurses use their knowledge and expertise, their relationship with other
members of the health team, and advances made available by the technology to assist
the childbearing family to achieve the goals and objectives its members have set.

CURRENT TRENDS

Changes in health care are influenced by the social, structural & technological
changes in the family and society. The role of the nurse is evolving from the primary
care giver to leader of the interdisciplinary care team according to these changes.
Advanced practice roles will increases as nurses assume more responsibility for client
care.
 Current Birth Settings
Woman can give birth in a hospital labor room, in a birthing room, in freestanding
birthing centre or at home. Health care consumers expect their childbirth experiences
will occur in a “natural” surrounding. To meet this expansion many hospitals have
instituted modified birth settings. The most common is the labor, delivery and
recovery (LDR) room where normal birth and recovery take place in one setting. The
women may be transferred to a post partum unit but the newborn will usually remain
with her. Some hospitals offer rooms in which woman can remain in the same setting
through the postpartum experience (a labor, delivery, recovery and post partum
(LDRP) room). In these settings family is encouraged to stay with the mother
overnight and nursing and medical care is available if an emergency arises. In addition
breastfeeding is encouraged to bond with the new infant. Also fathers are active
participants, not simply bystanders; siblings are encouraged to visit and meet their
new family member, not treated as walking resources of infection. In some hospitals
central nurseries have been eliminated and babies “room in” with their mothers.
Newborn remain with the mother and breast feed immediately after the birth. Free
standing birth centers are an alternative for parents seeking a homelike atmosphere.
Some of these settings have conveniences, such as a kitchen for family members, but
many freestanding birth canters did not have adequate technology and medical care
readily available if a complication to mother and baby arises.
 Mother – baby couplet care or Dyad care
Here, one nurse cares for the post partum mother and her new born as the single unit.
It focuses and adapts to both physical and the psychological needs of the mother, the
family and the neonate and fosters family unity.
 Primary Care Giver
Women can choose physicians or nurse midwives as primary care providers. Women
who choose nurse midwives as their primary care providers participate activity in

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childbirth decisions and receive fewer interventions such as epidural analgesia for
labor and episiotomy.
 Birth Related Experiences
Changes are occurring in the conduct of the second stage of labor, positions are varied
with more emphasis on up right posture. The arbitrary limit of two hours for the
second stage is less rigid as delayed pushing is instituted. Delayed pushing conserves
energy and results in fewer instrumental deliveries and is less costly. The rate of
episiotomy is declining, resulting in fewer severe perineal lacerations. The method of
analgesia varies depending on the condition and choices of the mother and preferences
of the provider. Some women prefer to experience the sensations of birth with little or
no analgesia. Others opt for epidural analgesia to provide comfort and control over
their behavior during the experience. With family centered care fathers, grand parents,
siblings may present for labor and birth. Fathers may be present for cesarean section
also.
 Early Discharge
Formerly even with uncomplicated birth women remained in the hospital for 3-4 days.
This provides ample time for the nurses to assess the family’s knowledge and skills
and complete essential teaching. In an effort to control costs early discharge is now
standard and women with little knowledge, experience or support now find themselves
discharged within 24 hrs or less after giving birth. In some settings discharge may
occur as early as 6 hours after birth. Legislation has been passed to ensure that
mothers and babies are permitted to stay in the hospital for of least 48 hours after
vaginal delivery and 96 hours after cesarean birth.
 Neonatal Security
Neonatal security in the hospital settings is received increasing attention. A number of
cases of baby napping and sending home the wrong baby have been reported. Parents
have expressed concerns for their infant’s safety. Security systems are being placed in
nurseries and nurses are required to wear photo identification or some other security
badges. Babies are also given identification badges with mother’s name, hospital
number, sex, date of birth and the related informations.
 Child Birth Education
Child birth education and parenting classes encourage the participation of a support
person; teach breathing and relaxation techniques and give general information about
birth, infant development and parenting. Other classes or parent support groups may
be organized for the weeks and months after birth. Focused and efficient teaching is
necessary to enable the parents and infants to make the transition safely from the
hospital to the home. Nurses may follow up telephone calls or have visits to assist
families needing information and reassurance.
 Family centered care
Based on the philosophy that health includes physical, social, mental and economic
aspects, the family centered approach assumes family as the basic unit of society.
Thus in family centered care the whole family is considered as one unit –the mother,
father, and the infant. Home visits help to assess their health and that of their infants
and do any necessary teaching. This trend towards home care is a positive one and that
this method of meeting the needs of childbearing families becomes standard practice.
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The nurse attends, educates and counsels all units. In family centered care, the nursery
and postpartum staffs are combined to form one mother-baby unit.
 Changes in Maternal –Newborn Nursing
Social, economic, political and technological factor have contributed to the many
changes that have occurred in maternal –newborn nursing within recent years. The
focus is now on childbirth as a familial process, with less technical interference,
greater humanism and a reaffirmation of natural birth process. In addition, the
importance of mother-baby bonding in the first hours and days of newborn’s life has
led to the encouragement of maximal mother-infant contact.
 Involving Consumers and Promoting Self-Care
Self-care is appealing to both clients and the health care system because of its
potential to reduce health care costs. Maternity care is especially suited to self-care
because childbearing is essentially health focused, women are usually well when they
enter the system, and visits to health care providers can present the opportunity for
health and illness interventions. Topic such as nutrition education, stress management,
smoking cessation, alcohol and drug treatment improvement of social support, and
parenting education are appropriate for such encounters.
 Emphasis on High-Technology Maternity Care
Advances in scientific knowledge and the large number of high risk pregnancies have
contributed to a health care system that emphasizes high-technology care. Maternity
care has branched out to preconception counseling, more and better scientific
techniques to monitor the mother and fetus, more definitive tests for hypoxia and
acidosis and neonatal intensive care units. Technologic advances have enabled many
infants to survive who might have otherwise died some years ago. Intrauterine fetal
surgery has been successfully performed, and high-risk prenatal clinics and neonatal
intensive care units (NICUs) provide care that the premature infant needs to survive.
Chromosomal studies and biochemical engineering have made identification of
risks and genetic counseling available to families who are at high risk for particular
conditions. Cord blood, taken from a newborn at birth, can be banked or stored for
later use if certain disorders arise. Telemedicine is an umbrella term for the use of
communication technologies and electronic information to provide or support health
care when the participants are separated by distance. Telemedicine permits specialist,
including nurses, to provide health care and consultation when distance separates them
from those needling care. For example, Baby Care Link is an Internet based program
that incorporates teleconferencing and the World Wide Web to enhance interactions
among health care providers, families, and community providers.
 The Human Genome project
The Human Genome Project is an international effort to identify and “map” all genetic
material present in the human body. The genes responsible for diseases such as cystic
fibrosis, fragile X syndrome, and breast cancer have been isolated and identified. The
findings of the Human Genome Project may enable gene therapy to replace missing
genes or alter defective genes, thus eliminating the cause of many genetic disorders.
The technique of inserting new or replacement genes into the human body has been
developed but still needs to be refined before it becomes a routine practice.
 Gender Selection
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Gender selection of the fetus can be accomplished by sperm separation. For example,
sperm carrying the Y chromosome can be identified and used for the fertilization of an
ovum to produce a male child. A child of a specific sex may be desired by a couple to
avoid passing on a genetic disorder that only affects a specific sex, or it may be
desired because the couple already has several children of one sex and now wants a
child of the opposite sex. Gender selection itself is not a new practice, however
pregnancies have been terminated when the sex of the fetus was not the “right one”,
and some newborns abandoned or killed if they were not of the desired sex. The
ability to determine and select the sex of the fetus before conception places an end to
inhumane practice, but the impact on the population and society needs to be
researched.
 Community-Based Care
A shift in settings, from acute care institution to the home, has been occurring. Even
childbearing women at high risk are cared for in the home. Technology previously
available only in the hospital is now found in the home. This has affected the
organizational structure of care, the skills required in providing such care and the costs
to consumers. Home health care also has a community focus.
 Research
The incorporation of research findings into practice is essential to develop a science
based practice. Practicing nurses can identify problems and related research literature
to identify studies that address their clinical concerns. They can develop procedures
and protocols based on published research. Health care providers need to support
researchers in their works.
 Future trends
Maternity nurses specialized in providing care of the women throughout the child
bearing cycle. Recent trends indicate that a new approach to women health during the
child bearing cycle is critical to the improvement of the overall health and well being
of the women and their infants. Maternity nurse can play a vital role in this process.
CURRENT ISSUES
 Decrease length of hospital stay
As health care becomes increasingly ambulatory-dominant, today’s mother is up and
out of hospital or health center in two or three days or even a day. Early discharge
poses a challenge to the nurse, who must provide nursing interventions during a brief
time frame and disseminate information, reinforce learning and affirm the mother’s
role in hours rather than days.
 Higher patient acuities
Multiple socio economic problems coupled with lack of knowledge about prenatal
care have contributed to increasing number of women who have neglected their health
during pregnancy. Many have anemia, hypertension, chronic illness and STDs. Large
numbers go into premature labor and delivery of LBW babies.

 Lack of facilities in rural areas

About 30% of deliveries in India are conducted by trained dais, which lacks scientific
knowledge. Most villages still have traditional dais to help with deliveries. This result

CONTEMPORARY PERSPECTIVES IN OBG Page 4

in lack of detection of prenatal problems for management and inadequate reporting of
morbidity.
 Legal issues in the delivery of care
Nursing standard of practice in perinatal and women’s health nursing has been
described by several organizations including the American Nurses Association (ANA)
and the Association for Women’s Health, Obstetric and Neonatal Nurses
(AWHONN). These standards reflect current knowledge and represent the levels of
practice agreed by the health care providers and leaders in the specialty. Because
nursing practice society and the health care system are dynamic rather than static,
standards will continue to change over time. In addition to these, more formalized
standards have their own policy and procedure books that outline standards to be
followed in that setting. In determining legal negligence, the care given is compared to
the standards of care. If the standard of care was not met and harm resulted, then
negligence occurred. The numbers of legal suits in the perinatal areas are typically
high. As a result malpractice insurance costs risen dramatically for physicians, nurse
midwives and nurses.
 Ethical Issues
Intrauterine fetal surgery, artificial insemination, genetic engineering, surrogate child-
bearing, infertility surgery, fetal research and the treatment of very low birth weight
infants have resulted in question about informer consent and allocation of resources.
Regulations and guidelines and ethic committees have become the common place.
Experts in ethics are increasingly consulted to examine theories for ethical decision
making, to assist in applying abstract theories to concrete situations and to educate the
public about method for making moral decisions.
 Increase in High Risk Pregnancies
The number of high pregnancies has increased, which means that a greater number of
pregnant women are at risk for poor pregnancy outcomes. Escalating drug use has
contributed to higher incidences of prematurity, LBW, congenital defects, learning
disabilities, and withdrawal symptoms in infants. Alcohol use in pregnancy has been
associated with miscarriages, mental retardation, LBW, and fetal alcohol syndrome.
The two most frequently reported maternal medical risk factors are hypertension
associated with pregnancy and diabetes.
 High Cost of Health Care
Health care is one of the fastest-growing sectors of the economy. A shift in
demographics, increased emphasis on high-cost technology and the liability costs of a
litigious society contribute to the high cost of care. Most researchers agree that the
cost of caring for the increased number of LBW infants in neonatal intensive care
units contributes significantly to the overall health care costs.
Nurses must become involved in the politics of cost containment because they, as
knowledgeable experts, can provide solutions to many of the health care problems at a
relatively low cost. Early postpartum discharge programs also are used to reduce
costs.
 Limited Access to Care
Barriers to access must be removed so that pregnancy outcomes can be improved. The
most significant barrier to access is the inability to pay. Lack of transportation and
CONTEMPORARY PERSPECTIVES IN OBG Page 5
dependent child care are other barriers. In addition to a lack of insurance and high
costs, a lack of providers for low-income women exists because many physicians
either refuse to take medicaid clients or take only a few such clients. This presents a
serious problem because a significant proportion of births are to mothers who receive
medicaid and those deliveries are conducted by midwives.

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