1. The Past, Present, and Future

The Past, Present, and Future


1. Contrast present-day concepts of maternity and child care with those of the past.

2. Recall the contributions of persons in history to the fields of maternity and pediatric care.

3. List the organizations concerned with setting standards for the nursing care of maternity and pediatric patients.

4. Name two international organizations concerned with maternity and pediatric care.

5. List three federal programs that assist mothers and infants.

6. State the influence of the federal government on maternity and pediatric care.

7. Discuss how culture affects childbirth and child care.

8. List four reasons why statistics are important.

9. Discuss common terms used in expressing vital statistics.

10. State two types of health care delivery systems in the United States.

11. Discuss the role of the advanced practice nurse.

12. List the five steps of the nursing process.

13. Understand the legal responsibilities of the nurse to report certain diseases or condition to the public health authorities.

14. Contrast a nursing care plan with a clinical pathway.

15. Define the Nursing Interventions Classification (NIC) and its relationship to the nursing process.

16. Describe the Nursing Outcomes Classification (NOC) and its influence on the nursing process.

17. Compare and contrast nursing and medical diagnosis frameworks with focus on North American Nursing Diagnosis Association International (NANDA-I) taxonomy.

18. Define critical thinking.

19. Discuss the role of critical thinking in the nursing process and in clinical judgment.

20. Discuss the role of critical thinking as it relates to test taking and lifelong learning.

21. Discuss the objectives of Healthy People 2020 as it relates to maternity and pediatric care.

22. Examine the importance of documentation as a nursing responsibility.

23. Describe the role of the community health nurse as a health care provider.

Key Terms

advanced practice nurses (p. 10)

advocate (p. 10)

birthing centers (p. 6)

clinical nurse specialist (CNS) (p. 10)

clinical pathways (p. 12)

cost containment (p. 6)

critical thinking (p. 13)

cultural awareness (p. 7)

cultural competence (p. 7)

cultural sensitivity (p. 7)

culture (p. 7)

diagnosis-related groups (DRGs) (p. 9)

documentation (p. 16)

empowerment (p. 2)

evidence-based practice (p. 13)

family care plan (p. 16)

full inclusion (p. 10)

genomics (p. 7)

Health Information Portability and Accountability Act (HIPAA) (p. 4)

health maintenance organizations (HMOs) (p. 9)

Healthy People 2020 (p. 17)

labor, delivery, and recovery (LDR) rooms (p. 6)

mainstream (p. 10)

midwives (p. 6)

morbidity (mŏr-BĬD-ĭ-tē, p. 3)

mortality (mŏr-TĂL-ĭ-tē, p. 3)

nursing care plan (p. 11)

nursing process (p. 11)

obstetrician (ŏb-stĕ-TRĬSH-ĕn, p. 2)

obstetrics (ŏb-STĔT-rĭks, p. 2)

pediatric nurse practitioner (PNP) (p. 10)

pediatrics (pē-dē-ĂT-rĭks, p. 2)

preferred provider organizations (PPOs) (p. 9)

puerperium (pū-ĕr-PĒ-rē-ŭm, p. 2)

statistics (stă-TĬS-tĭks, p. 12)

SBAR (or S-BAR) (ĔS-băr) (p. 16)

image  http://evolve.elsevier.com/Leifer

The word obstetrics is derived from the Latin term obstetrix, which means “stand by.” It is the branch of medicine that pertains to care of women during pregnancy, childbirth, and the postpartum period (puerperium). Maternity nursing is the care given by the nurse to the expectant family before, during, and following birth.

A physician specializing in the care of women during pregnancy, labor, birth, and the postpartum period is an obstetrician. These physicians perform cesarean deliveries and treat women with known or suspected obstetric problems as well as attend normal deliveries. Many family physicians and certified nurse-midwives also deliver babies.

Pediatrics is defined as the branch of medicine that deals with the child’s development and care and the diseases of childhood and their treatment. The word is derived from the Greek pais, paidos, meaning “child,” and iatreia, “cure.”

Family-centered care recognizes the strength and integrity of the family and places it at the core of planning and implementing health care. The family members as caregivers and decision makers are an integral part of both obstetric and pediatric nursing. The philosophy, goals, culture, and ethnic practices of the family contribute to their ability to accept and maintain control over the health care of family members. This control is called empowerment. The nurse’s role in maternity and pediatric family-centered care is to enter into a contract or partnership with the family to achieve the goals of health for its members.

The Past


The skill and knowledge related to obstetrics have evolved over centuries. The earliest records concerning childbirth are in the Egyptian papyruses (circa 1550 BC). Later advances were made by Soranus, a Greek physician who practiced in second-century Rome and who is known as the father of obstetrics. He instituted the practice of podalic version, a procedure used to rotate a fetus to a breech, or feet-first, position. Podalic version is important in the vaginal delivery of the second infant in a set of twins. In this procedure the physician reaches into the uterus and grasps one or both of the infant’s feet to facilitate delivery. Planned cesarean birth is safer than podalic version and today is used more often.

With the decline of the Roman Empire and the ensuing Dark Ages, scientific exploration and associated medical improvements came to a halt. During the nineteenth century, however, Karl Credé (1819-1892) and Ignaz Semmelweis (1818-1865) made contributions that improved the safety and the health of mother and child during and after childbirth. In 1884 Credé recommended instilling 2% silver nitrate into the eyes of newborns to prevent blindness caused by gonorrhea. Credé’s innovation has saved the eyesight of incalculable numbers of babies.

Semmelweis’s story is a classic in the history of maternity care. In the 1840s he worked as an assistant professor in the maternity ward of the Vienna general hospital. There he discovered a relationship between the incidence of puerperal fever (or “childbed fever”), which caused many deaths among women in lying-in wards, and the examination of new mothers by student doctors who had just returned from dissecting cadavers. Semmelweis deduced that puerperal fever was septic, contagious, and transmitted by the unwashed hands of physicians and medical students. Semmelweis’s outstanding work, written in 1861, is titled The Causes, Understanding, and Prevention of Childbed Fever. Tragically, not until 1890 was his teaching finally accepted.

Louis Pasteur (1822-1895), a French chemist, confirmed that puerperal fever was caused by bacteria and could be spread by improper handwashing and contact with contaminated objects. The simple, but highly effective, procedure of handwashing continues to be one of the most important means of preventing the spread of infection in the hospital and the home today.

Joseph Lister (1827-1912), a British surgeon influenced by Pasteur, experimented with chemical means of preventing infection. He revolutionized surgical practice by introducing antiseptic surgery.


Methods of child care have varied throughout history. The culture of a society has a strong influence on standards of child care. Many primitive tribes were nomads. Strong children survived, whereas the weak were left to die. This practice of infanticide (French and Latin infans, “infant,” and caedere, “to kill”) helped to ensure the safety of the group. As tribes became settled, more attention was given to children, but they were still frequently valued only for their productivity. Certain peoples, such as the Egyptians and the Greeks, were advanced in their attitudes. The Greek physician Hippocrates (460-370 BC) wrote of illnesses peculiar to children.

In the Middle Ages, the concept of childhood did not exist. Infancy lasted until about age 7 years, at which time the child was assimilated into the adult world. The art of that time depicts children wearing adult clothes and wigs. Most children did not attend school.

Christianity had a considerable impact on child care. In the early seventeenth century, several children’s asylums were founded by Saint Vincent de Paul. Many of these eventually became hospitals, although their original concern was for the abandoned. The first children’s hospital was founded in Paris in 1802. In the United States, numerous homeless children were cared for by the Children’s Aid Society, founded in New York City in 1853. In 1855 the first pediatric hospital in the United States, The Children’s Hospital of Philadelphia, was founded.

Abraham Jacobi (1830-1919) is known as the father of pediatrics because of his many contributions to the field. The establishment of pediatric nursing as a specialty paralleled that of departments of pediatrics in medical schools, the founding of children’s hospitals, and the development of separate units for children in foundling homes and general hospitals. By the 1960s, separate pediatric units were also common in hospitals. Parents were restricted by rigid visiting hours that allowed parent-infant contact for only a few hours each day; when medically indicated, nursing mothers were allowed to enter the pediatric unit for 1 hour at a time to breastfeed their infants.

Obstetric and Pediatric Care in the United States

The immigrants who reached the shores of North America brought with them a wide variety of practices and beliefs about the birth process. Many practices were also contributed by the Native American nations. Most deliveries in the early United States were attended by a midwife or relative. One physician, Samuel Bard, who was educated outside the United States, is credited with writing the first American textbook for midwives in 1807.

As a young Harvard physician, Oliver Wendell Holmes (1809-1894) wrote a paper detailing the contagious nature of puerperal fever but he, like Semmelweis, was widely criticized by his colleagues. Eventually, the “germ theory” became accepted, and more mothers and babies began to survive childbirth in the hospital.

Before the 1900s most babies were born at home. Only very ill patients were cared for in lying-in hospitals. Maternal and child morbidity and mortality were high in such institutions because of crowded conditions and unskilled nursing care. Hospitals began to develop training programs for nurses. As the medical profession grew, physicians developed a closer relationship with hospitals. This, along with the advent of obstetric instruments and anesthesia, caused a shift to hospital care during childbirth. By the 1950s, hospital practice in obstetrics was well-established. By 1960, more than 90% of births in the United States occurred in hospitals.

However, hospital care during that time did not embrace the family-centered approach. Often the father waited in a separate room during the labor and birth of his child. The mother was often sedated with “twilight sleep” and participated little during labor and delivery. After birth the infant was not reunited with the parents for several hours, which resulted in a delay of parent-infant bonding.

Organizations concerned with setting standards for maternity and pediatric nursing developed. These included the American College of Nurse-Midwives (ACNM); the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), which was formerly the Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG); and the Division of Maternal Nursing within the American Nurses Association (ANA). The American Academy of Pediatrics (AAP), made up of pediatricians from across the nation, has established a position of leadership in setting health standards for children.

image Nursing Tip

The ANA develops standards of practice that serve as a guide to meet some current challenges. These standards are used when policies and procedures are established. Also, each state has a nurse practice act that determines the scope of practice for the registered nurse, the practical nurse, and the certified nurse assistant. Because these descriptions vary from state to state, nurses must keep informed about the laws in the state where they are employed.

Government Influences in Maternity and Pediatric Care


The high mortality of mothers and infants motivated action by the federal government to improve care. The following is a chronological list of some of the important milestones in United States history related to maternity and pediatric care and safety:

• The Sheppard-Towner Act of 1921 provided funds for state-managed programs for maternity care.

• Title V of the Social Security Act, passed in 1935, provided funds for maternity care.

• The Fair Labor Standards Act, passed in 1938, established a general minimum working age of 16 years and a minimum working age of 18 years for jobs considered hazardous. More importantly, this act paved the way for the establishment of national minimum standards for child labor and provided a means of enforcement.

• The National Institutes of Health (NIH) established support for maternity research and education (1962).

• Head Start programs were established to increase educational exposure of preschool children (1966).

• The Women’s, Infant’s and Children’s (WIC) program was established to provide supple­mental food and education for families in need of assistance (1966).

• The National Center for Family Planning was established to provide contraceptive information (1970).

• In 1974, the government passed the Child Abuse Prevention and Treatment Act (CAPTA).

• In 1975, the Education for All Handicapped Children Act provided for support and public education of handicapped children.

• The Title V amendment of the Public Health Services Act established maternal-infant care centers in public clinics (1981).

• In 1982, the Community Mental Health Center was funded; and the Missing Children’s Act was passed, providing a nationwide clearinghouse for missing children.

• The Family and Medical Leave Act (FMLA) of 1993 enabled employees to take 12 weeks of unpaid leave to care for newborns or family members who were ill without losing benefits or pay status in their jobs.

• Title XIX of the Medicaid program increased access to care by indigent women (1993).

• The Health Information Portability and Accountability Act (HIPAA), enacted in 2003, set standards to protect patients’ health information. Patients are allowed access to their medical records and control over how their personal information is disclosed.

• The Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted in 2009 to extend HIPAA regulations by protecting electronic health records.

image Legal and Ethical Considerations


Health care personnel are expected to maintain strict confidentiality concerning all patient information. HIPAA regulations mandate that the names and personal information of patients be kept in a secure and private place. Nurses and other health care personnel must maintain strict confidentiality concerning all patient information. The HITECH addition to HIPAA enacted in July 2009 includes confidentiality requirements involving the monitoring and management of access to electronic health records.

Laws requiring the licensing of physicians and pharmacists indirectly affect the health of children and of the general public. Protection is also afforded by the Pure Food and Drug Act, which has allowed for governmental control over medicines, poisons, and the purity of foods. Programs for disaster relief, care and rehabilitation of handicapped children, foster child care, family counseling, family day care, protective services for abused or neglected children, and education of the public are maintained and supported by governmental and private agencies. State licensing bureaus control the regulation of motor vehicles. Car seats for infants and children are currently mandatory. Protection of the public by law enforcement agencies is important because automobile accidents rank among the leading causes of injury and death in children.

The Children’s Bureau.

Lillian Wald, a nurse who was interested in the welfare of children, is credited with suggesting the establishment of a federal children’s bureau. Once the Children’s Bureau was established in 1912, it focused its attention on the problem of infant mortality. This program was then followed by one that dealt with maternal mortality. These programs eventually led to birth registration in all states. In the 1930s, the Children’s Bureau investigations led to the development of hot lunch programs in many schools. Today the Children’s Bureau is administered under the auspices of the Department of Health and Human Services.

image Nursing Tip

Community programs such as foster grandparents programs, home health or parent aides, and telephone hotlines for children home alone after school are of particular value to dysfunctional or isolated families.

White House Conferences.

The First White House Conference on Children and Youth was called by President Theodore Roosevelt in 1909. It continues to be held every 10 years. In the White House Conference on Child Health and Protection of 1930, the Children’s Charter was written (Box 1-1). The charter lists 17 statements related to the needs of children in the areas of education, health, welfare, and protection and is considered one of the most important documents in child care history. This declaration has been widely distributed throughout the world.

Box 1-1

The Children’s Charter of 1930*

I. For every child spiritual and moral training to help him or her to stand firm under the pressure of life.

II. For every child understanding and the guarding of personality as a most precious right.

III. For every child a home and that love and security which a home provides; and for those children who must receive foster care, the nearest substitute for their own home.

IV. For every child full preparation for the birth; the mother receiving prenatal, natal, and postnatal care; and the establishment of such protective measures as will make childbearing safer.

V. For every child protection from birth through adolescence, including periodic health examinations and, where needed, care of specialists and hospital treatment; regular dental examinations and care of the teeth; protective and preventive measures against communicable diseases; the ensuring of pure food, pure milk, and pure water.

VI. For every child from birth through adolescence, promotion of health, including health instruction and health programs, wholesome physical and mental recreation, with teachers and leaders adequately trained.

VII. For every child a dwelling place safe, sanitary, and wholesome, with reasonable provisions for privacy; free from conditions which tend to thwart development; and a home environment harmonious and enriching.

VIII. For every child a school which is safe from hazards, sanitary, properly equipped, lighted, and ventilated. For younger children nursery schools and kindergartens to supplement home care.

IX. For every child a community which recognizes and plans for needs; protects against physical dangers, moral hazards, and disease; provides safe and wholesome places for play and recreation; and makes provision for cultural and social needs.

X. For every child an education which, through the discovery and development of individual abilities, prepares the child for life and through training and vocational guidance prepares for a living which will yield the maximum of satisfaction.

XI. For every child such teaching and training as will prepare him or her for successful parenthood, homemaking, and the rights of citizenship and, for parents, supplementary training to fit them to deal wisely with the problems of parenthood.

XII. For every child education for safety and protection against accidents to which modern conditions subject the child—those to which the child is directly exposed and those which, through loss or maiming of the parents, affect the child directly.

XIII. For every child who is blind, deaf, crippled, or otherwise physically handicapped and for the child who is mentally handicapped, such measures as will early discover and diagnose his handicap, provide care and treatment, and so train the child that the child may become an asset to society rather than a liability. Expenses of these services should be borne publicly where they cannot be privately met.

XIV. For every child who is in conflict with society the right to be dealt with intelligently as society’s charge, not society’s outcast; with the home, the school, the church, the court, and the institution when needed, shaped to return the child whenever possible to the normal stream of life.

XV. For every child the right to grow up in a family with an adequate standard of living and the security of a stable income as the surest safeguard against social handicaps.

XVI. For every child protection against labor that stunts growth, either physical or mental, that limits education that deprives children of the right of comradeship, of play, and of joy.

XVII. For every rural child as satisfactory schooling and health services as for the city child, and an extension to rural families of social, recreational, and cultural facilities.

The 1980 White House Conference on Families focused on involving the states at the grassroots level. A series of statewide hearings were held to identify the most pressing problems of families in the various localities. A tremendous range of viewpoints on many subjects was shared, and specific recommendations were made.

International Year of the Child.

The year 1979 was designated as the International Year of the Child (IYC). Its purpose was to focus attention on the critical needs of the world’s 1.5 billion children and to inspire the nations, organizations, and individuals of the world to consider how well they provide for children (U.S. Commission of the International Year of the Child, 1980). At this time, the United Nations reaffirmed the Declaration of the Rights of the Child (Box 1-2). Two international organizations concerned with children are the United Nations International Children’s Fund (UNICEF) and the World Health Organization (WHO).

Box 1-2

The United Nations Declaration of the Rights of the Child*

The General Assembly proclaims that the child is entitled to a happy childhood and that all should recognize these rights and strive for their observance by legislative and other means:

1. All children without exception shall be entitled to these rights regardless of race, color, sex, language, religion, politics, national or social origin, property, birth, or other status.

2. The child should be protected so that he or she may develop physically, mentally, morally, spiritually, and socially in freedom and dignity.

3. The child is entitled at birth to a name and nationality.

4. The child is entitled to healthy development which includes adequate food, housing, recreation, and medical attention. He or she shall receive the benefits of Social Security.

5. The child who is handicapped physically, mentally, or emotionally shall receive treatment, education, and care according to his or her need.

6. The child is entitled to love and a harmonious atmosphere, preferably in the environment of his or her parents. Particular love, care, and concern need to be extended to children without families and to the poor.

7. The child is entitled to a free education and opportunities for play and recreation and to develop his or her talents.

8. The child shall be the first one protected in times of adversity.

9. The child shall be protected against all forms of neglect, cruelty, and exploitation. He or she should not be employed in hazardous occupations or before the minimum age.

10. The child shall not be subjected to racial or religious discrimination. The environment should be peaceful and friendly.

Department of Public Health.

The Department of Public Health bears a great deal of responsibility for the prevention of disease and death during childhood. Preventive efforts are made on national, state, and local levels. This department sees to the inspection of the water, milk, and food supplies of communities and enforces the maintenance of proper sewage and garbage disposal. Epidemics are investigated and, when necessary, persons capable of transmitting diseases are isolated. The Department of Public Health is also concerned with the inspection of housing.

image Legal and Ethical Considerations

Reportable Situations

The nurse has a legal responsibility to report certain diseases or conditions to the local public health authorities. A reportable disease is an illness that poses a health hazard to the public, such as a foodborne infection, tuberculosis, sexually transmitted infection (STI), or other communicable condition (see Chapter 32). Suspected child abuse or suicidal behavior must be reported immediately to protect the child from further harm. Required reporting forms are available from the employer or the public health department. The nurse must have a basic understanding of legal and ethical responsibilities and the role of the health care team to be able to use critical thinking skills and provide meaningful support to the family.

The Present

Family-Centered Care

In family-centered childbearing, the family is recognized as a unique system. Every family member is affected by the birth of a child; therefore, family involvement during pregnancy and birth is seen as constructive and, indeed, necessary for bonding and support. To accommodate family needs, alternative birth centers, birthing rooms, rooming-in units, and mother-infant coupling have been developed. These arrangements are alternatives to the previous standard of separate areas for labor and delivery, which made it necessary to transport a mother from one area to another and fragmented her care.

The three separate sections of the maternity unit—labor-delivery, postpartum, and newborn nursery—have merged. The whole sequence of events may take place in one suite of labor, delivery, and recovery (LDR) rooms. The patient is not moved from one area to another, but receives care during labor and delivery and then remains in the same room to recover and care for her new infant. The rooms are often decorated to look homelike.

Freestanding birthing centers outside the traditional hospital setting are popular with low-risk maternity patients. These birthing centers provide compre­hensive care, including antepartum, labor-delivery, postpartum, mothers’ classes, lactation classes, and follow-up family planning. Home birth using midwives is not a current widespread practice, because malpractice insurance is expensive and emergency equipment for unexpected complications is not available.

Financial Considerations

Cost containment is the efficient and effective use of resources. It includes monitoring and regulating expenditures of funds and involves the institution’s budget. At first, cost containment influenced maternity care by requiring the discharge of mother and newborn in 24 hours or less after delivery. As a result of problems that occurred, current legislation allows a 48-hour hospital stay for vaginal deliveries and a stay of 4 days for a cesarean section.

Changing Perceptions of Childbearing

Current maternity practice focuses on a high-quality family experience. Childbearing is seen as a normal and healthy event. Parents are prepared for the changes that take place during pregnancy, labor, and delivery. They are also prepared for the changes in family dynamics after the birth. Treating each family according to its individual needs is considered paramount.

During the 1950s, the hospital stay for labor and delivery was 1 week. The current average stay in uncomplicated cases is 2 days. Routine follow-up of the newborn takes place within 2 weeks. A nurse visits the homes of infants and mothers who appear to be at high risk.


Throughout history, women have played an important role as birth attendants or midwives. The first school of nurse-midwifery opened in New York City in 1932. There are many accredited programs across the United States, all located in or affiliated with institutions of higher learning. The certified nurse-midwife (CNM) is a registered nurse who has graduated from an accredited midwife program and is nationally certified by the American College of Nurse-Midwives. The CNM provides comprehensive prenatal and postnatal care and attends uncomplicated deliveries. The CNM ensures that each patient has a backup physician who will assume her care should a problem occur.

Role of the Consumer

Consumerism has played an important part in family-centered childbirth. In the early 1960s, the natural childbirth movement awakened expectant parents to the need for education and involvement. Prepared childbirth, La Leche League (breastfeeding advocates), and Lamaze classes gradually became accepted. Parents began to question the routine use of anesthesia and the exclusion of fathers from the delivery experience.

Today, a father’s attendance at birth is common. Visiting hours are liberal, and extended contact with the newborn is encouraged. The consumer continues to be an important instigator of change. Consumer groups, with the growing support of professionals, have helped to revise restrictive policies once thought necessary for safety. It has been demonstrated that informed parents can make wise decisions about their own care during this period if they are adequately educated and given professional support.

Cultural Considerations

Culture is a body of socially inherited characteristics that one generation hands down to the next. Culture consists of values, beliefs, and practices shared by members of the group. Culture becomes a patterned expression of the thoughts and actions (called traditions) and affects the way patients respond to health care.

The United States is a culturally diverse nation, and nurses must develop cultural awareness and cultural sensitivity to practices and values that differ from their own. Only this way nurses can develop the cultural competence that will enable them to adapt health care practices to meet the needs of patients from various cultures.

The cultural background of the expectant family strongly influences its adaptation to the birth experience. Nursing Care Plan 1-1 lists nursing interventions for selected diagnoses that pertain to cultural diversity. One way in which the nurse gains important information about an individual’s culture is to ask the pregnant woman what she considers normal practice. Data collection questions might include the following:

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Aug 7, 2016 | Posted by in NURSING | Comments Off on 1. The Past, Present, and Future

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