NCM 33 FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING

FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING THEORIES RELATED TO MATERNAL AND CHILD NURSING
- This framework provides guidance and direction to implementation of programs and interventions in - One of the requirements of a profession (together with other critical determinants, such as member-set
maternal/reproductive, newborn and child health. standards, monitoring of practice quality, and participation in research) is that the concentration of a
discipline’s knowledge flows from a base of established theory.
OBSTETRICS – care of woman during childbirth; derived from Greek “obstare” which means to keep watch - Nursing theorists offer helpful ways to review clients so that nursing activities can best meet client needs—e.g.
PEDITRICS – derived from Greek word, “pais” meaning child 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.
FOCUS OF MCN – care of childbearing and childbearing families
- Only with this broad theoretical focus can nurses appreciate the significant effect on a family of a child’s illness
PRIMARY GOAL OF MCN or of the introduction of a new member.
1. Promotion and maintenance of Optimal Family Health
SUMMARY OF NURSING THEORIES
2. Promotion of optimum health of the woman
THEORIST MAJOR CONCEPTS OF THEORY EMPHASIS OF CARE
3. Maintenance of optimum health of the newborn
Patricia Nursing is a caring relationship. Nurses grow from Assess a pregnant woman as a whole. An
4. Promotion and Maintenance of optimum health of the woman and the newborn
Benner novice to expert as they practice in clinical expert nurse is able to do this intuitively
5. Prevention and maintenance of optimum health of the woman and the newborn
settings. from knowledge gained from practice.
GOALS OF MCN ARE BROAD BECAUSE THE SCOPE OF PRACTICE OR RANGE OF PRACTICE INCLUDES THE Madeleine Essence of nursing is care. To provide transcultural Assess a pregnant woman’s family for
FF: Leininger care, nurse focuses on the study and analysis of beliefs about healing. Incorporate these
1. Preconceptual Health Care different cultures with respect to caring behavior. into care.
2. Care of women during 3 trimesters of pregnancy Dorothea The focus of nursing is on the individual; clients are Arrange overbed table so Terry can feed
- 1st trimester (1st – 3rd month); 2nd trimester (4th – 6th month); 3rd trimester (7th – 9th month) Orem assessed in terms of ability to complete self-care. herself; urge her to participate in care by
3. Care of women during Puerperium or 4th Trimester (6 weeks after childbirth) doing as much for herself as she can.
4. Care of infants during Perinatal Period (6 weeks before conception and 6 weeks after birth)
5. Care of children from birth to adolescent KEY RESPONSIBILITIES AND DUTIES OF MCN NURSE
- Neonatal (28 days of life); Infancy (1-12 months); Adolescence (after 18 years old) 1. Provide evidenced based assessments with additional emphasis on health promotion and well-being
6. Care in setting as varied as the birthing room, the PICU, and the home according to the framework.
2. Provide information, support, advice, and appropriate referrals relating to children and parents well-being,
PHILOSPHIES OF MCN: including health, immunization, breast feeding, antenatal, and post-natal care.
1. MCN is family centered; assessment must include both family and individual assessment 3. Provide an innovative approach to flexible service delivery that will encourage access and participation for all
2. MCN is community centered; health of families depends on and influences the health of communities families in the community.
3. MCN is evidenced based because critical knowledge increases 4. Provide a focus on prevention, early detection and intervention of the health and well-being concerns of
4. MCN includes independent nursing functions because teaching and counselling are major interventions vulnerable infants, children and their families through an interdisciplinary and integrated service response.
5. MCN Nurse, Advocate (protects the right of family members, including fetus) 5. Recognize and facilitate the access to families of cultural and linguistic diverse backgrounds.
6. Health Promotion and Disease Prevention to protect health of new generation 6. Promote and provide information and advice about vaccinating against preventable diseases in cooperation
7. MCN is a challenging role for nurses with Council’s Immunization department.
7. Act as advocate for children, parents, the community & the Maternal & Child Health Service as appropriate.
FAMILY – BASIC UNIT OF SOCIETY
8. Proactively participate in the Maternal and Child Health Service team in the development and
- In all settings and types of care, keeping family at the center of care or considering family as the primary unit of
implementation of continuous improvements to the service.
care is an essential goal because the level of a family’s functioning affects the health status of its members.
9. Participate in relevant networks & outreach programs concerning young children and families as requested.
- The family is the basic unit of society
- Families represent racial, ethnic, cultural, and socioeconomic diversity. FRAMEWORK FOR MCN
- Children grow both individually and as a part of a family. 1. Nursing Process 2. Evidenced 3. Nursing 4. Nursing
- A family centered approach enables nurses to better understand individuals and their effect on others, and in (ADPIE) Based Practice Research Theory
turn, to provide holistic care.
NCM 33 FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING

4 PHASES OF HEALTH CARE TRENDS IN HEALTH CARE ENVIRONMENT

1. HEALTH PROMOTION – educating clients to be aware of good health through teaching and role modelling. 1. COST CONTAINMENT – reducing the cost of health by closely monitoring the cost of personnel, use and
E.g. Family planning, teach the importance of safe sex practice, importance of immunizations. brands of supplies, length of hospital stays, number of procedures carried out, number of referrals while
2. HEALTH MAINTENANCE – intervening to maintain health when risk of illness is present. E.g. Encourage maintaining quality care.
prenatal care, importance of safeguarding homes by childproofing it against poisoning 2. INCREASING ALTERNATIVE SETTINGS AND STYLES FOR HEALTH CARE
3. HEALTH RESTORATION – diagnosing and treating illness using interventions that will return client to wellness LDRP ROOMS (Labor – Delivery – Recovery – Postpartum) a more natural childbirth environment as a
fast. E.g. Care of child during illness, care of woman during pregnancy complication. birthing room. Family members are invited to stay to be part of childbirth.
4. HEALTH REHABILITATION – preventing further complications from an illness; bringing client back to an  Retail Clinics or Emergent Care Clinics located in shopping malls
optimal state of wellness; helping client accept inevitable death. E.g. Encourage therapies & medications  Ambulatory Clinics or at home to avoid long hospital stays for women and children
3. INCLUDING FAMILY IN HEALTH CARE
TRENDS IN MATERNAL AND CHILD HEALTH NURSING POPULATION
4. INCREASING INTENSIVE CARE UNITS
CLIENT ADVOCACY – safeguarding and advancing the interests of clients and their families.
NICU (Neonatal Intensive Care Unit) or ICN (Intensive Care Nursery)
NURSING IMPLICATIONS
PICU (Pediatric Intensive Care Unit)
Families are smaller in size Fewer family members are present as support people in times of crisis
5. REGIONALIZING INTENSIVE CARE – e.g. Premature infant transferred to regional hospital.
Role of nurse: Fulfil the role
Increased Single Parents (most Fewer financial resources especially woman 6. INCREASING THE USE OF ALTERNATIVE TREATMENT MODALITIES – alternative method of
common type of parent in US) Role of Nurse: Inform parents of care options and back up opinion therapies such as acupuncture and therapeutic touch; herbal remedies
Increased mothers working outside Healthcare must be scheduled at times a working aren’t can care for 7. INCREASING RELIANCE ON HOME CARE – decreased hospital stay
home at least part time (90%) her own self or bring a child for care. 8. INCREASING USE OF TECHNOLOGY – use of internet, charting in computer, using Doppler
Role of Nurse: Discuss selection of child care centers 9. FREE BIRTHING – women giving birth without health care provider supervision; unassisted birth
Families are more mobile, Good interviewing and health monitoring are necessary so health 10. LAMAS – breathing techniques
Increased number of homeless database can be established and continuity of care.
women and children LEGAL CONSIDERATIONS OF MCN PRACTICE
Child and Intimate Partner Abuse Screening for child or intimate partner abuse, Nurses must be aware of 1. Identifying and reporting child abuse
legal responsibilities for reporting abuse. 2. Child can bring a lawsuit when they reach legal age
Families are more health conscious Provide Health Education 3. Informed consent for invasive procedure and any risk that may harm the fetus
Health care should respect cost Comprehensive care is necessary in primary care settings because 4. In divorced or blended families, nurse has the right to give consent
contaminent referral to specialists may no longer be an option; Health insurance is Note: Nurses are legally responsible to protect the rights of their client and documentation is essential to protect
not available in all families. nurse and justify his or her actions.

MEASURING MATERNAL AND CHILD HEALTH/STATISTICAL TERMS USED TO REPORT MATERNAL AND ETHICAL CONSIDERATIONS OF PRACTICE
CHILD HEALTH 1. Conception issues (In vitro fertilization, embryo transfer, cloning, stem cell research, surrogate mothers)
1. BIRTH RATE – number of births per 1000 population 2. Abortion
2. FERTILITY RATE – number of pregnancies per 1000 women of childbearing age 3. Fetal rights vs rights of the mother
3. FETAL DEATH RATE – number of fetal deaths weighing more than 500 g or more per 1000 live births 4. Use of fetal tissue for research
4. NEONATAL DEATH RATE – 1st 28 days of life; Infant is called Neonate 5. Resuscitation
5. PERINATAL DEATH RATE – Perinatal Period – 6 weeks before conception and 6 weeks after childbirth. 6. Number of procedures or degree of pain that a child should ask to achieve better health
Number of deaths of fetuses weighing >500 g and within the first 28 days of life per 1000 birth. 7. Balance between modern technology and quality of life
6. INFANT MORTALITY RATE – number of deaths per 1000 live births in the first 12 months of life.
7. CHILD MORTALITY RATE – number of deaths per 1000 population in children; 1-4 y/o.
8. MATERNAL MORTALITY RATE – number of maternal deaths per 100,000 live births that occur as direct result
of reproductive process.
NCM 33 FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING

WHAT IS THE MNCHN? BEmONC

- The rate of decline in maternal and newborn mortality has decelerated in the past decades. - BEmONC facility shall consist of the core district hospital.
- In response, the Department of Health (DOH) issued Administrative Order 2008-2009 “Implementing Heath - For geographically isolated/disadvantaged areas/densely populated areas, the designated BeMONC facilities
Reforms for Rapid Reduction of Maternal and Neonatal Mortality”. are the following:
- This policy issuance provides the strategy for rapidly reducing maternal and neonatal deaths through the o Rural Health Unit, Barangay Health Station, Lying-in Clinics and Birthing Homes.
provision of a package of maternal, newborn, child health and nutrition (MNCHN) services. o Accessibility within 1 hour from residence or referring facility within the ILHZ (Inter-local Health Zones)
- If BEmONC (Basic Emergency Obstetric and Newborn Care) is hospital based, blood transfusion services
MATERNAL, NEWBORN, CHILD HEATH, & NUTRITION (MNCHN) which may or may not include blood collection and screening will be provided.
- It applies specific policies and actions for local health systems to systematically address health risks that lead to - Shall operate within 24 hours with 6 signal obstetric function.
maternal and especially neonatal deaths which comprise half of the reported infant mortalities. - Shall have access to communication and transportation facilities to mobilize referrals.
- The goal of rapidly reducing maternal and neonatal mortality shall be achieved through effective population- - Staff composition: (1) Medical Doctor, (1) Registered Nurse, (1) Registered Midwife.
wide provision and use of integrated MNCHN services as appropriate to any locality in the country. The - A BEmONC based in RHUs, BHS, lying-in clinics, or birthing homes can either be a stand-alone facility or
strategy aims to achieve the following intermediate results: composed of a network of facilities and skilled health professionals capable of delivering the 6 signal
1. Every pregnancy is wanted, planned, and supported functions.
2. Every pregnancy is adequately managed throughout its course
3. Every delivery is facility-based managed by skilled birth attendants/skilled health professionals STANDALONE BEmONC
4. Every mother and newborn pair secures proper post-partum and newborn care with smooth transitions to - A standalone BEmONC is a capable facility that is typically an RHU which has the complement of skilled
the women’s health care package for the mother and child survival package for the newborn. health professionals such as doctors, nurses, midwifes, and medical technologists. BEmONCs operating as a
network of facilities and providers can consist of RHUs, BHU, lying-in clinics, or birthing homes operated by
DEFINITION OF TERMS skilled health professionals.
ANTENATAL CARE COVERAGE - At the minimum, this can be operated by a midwife who is either under supervision by the rural health
- An indicator of access and use of health care during pregnancy. physician or has referral arrangements with a hospital or doctor trained in the management of maternal and
- it constitutes screening for health and socioeconomic conditions likely to increase the possibility of specific newborn emergencies. Under this arrangement, a midwife can provide lifesaving interventions within the
adverse pregnancy outcomes, providing therapeutic interventions known to be effective; and educating intent of [A. O. 2010-0014].
pregnant women about planning for safe birth, emergencies during pregnancy and how to deal with them - BEmONCs shall be supported by emergency transport and communication facilities.
- The provision of blood transfusion services in non-hospital BEmONCs shall be dependent on presence of
BASIC EMERGENCY OBSTETRIC AND NEWBORN CARE (BEmONC) qualified personnel and required equipment and supplies.
Capable network of facilities and providers that can perform the following 6 signal obstetric functions:
1. Parenteral administration of oxytocin in the third stage of labor COMMUNITY HEALTH TEAM (CHT)
2. Parenteral administration of loading dose of anti-convulsants - Composed of community health volunteers (e.g. Barangay Health Teams, Women’s Health Teams and the like)
3. Parenteral administration of initial dose of antibiotics led by a midwife that can provide community level care and services during the pre-pregnancy, pregnancy,
4. Performance of assisted deliveries (Imminent Breech Delivery) delivery, and post-partum period.
5. Removal of retained products of conception
6. Manual removal of retained placenta. FUNCTIONS OF CHTs
These facilities are also able to provide emergency newborn interventions, which include the minimum:  Improve utilization of services by women and their families by master listing pregnant women and women of
1. Newborn resuscitation reproductive age, assessing health risks of women and their families, assisting families in the preparation of
2. Treatment of neonatal sepsis/infection health plans, provide information on available services, good health practices including financing options.
3. Oxygen support. It shall also be capable of providing blood transfusion services on top of its standard  Organize outreach services especially for remote areas and organize transportation and communication
functions. systems within the community.
 Refer high risk pregnancies to appropriate providers, report maternal and neonatal deaths, follow-up of clients
for family planning, nutrition and maternal and child care.
 Facilitate discussions of relevant community health issues, like those affecting women and children.
NCM 33 FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING

→ A thorough evaluation of the needs of patients with mild complications will determine the frequency of
COMMUNITY LEVEL PROVIDERS follow-up of these cases by the rural health unit, city health clinic or puericulture center.
- Refer primarily to Rural Health Units (RHUs), Barangay Health Stations (BHS), private outpatient clinics and its PATIENTS WITH POTENTIALLY SERIOUS COMPLICAITONS
health staff (e.g. midwife) and volunteer health workers (e.g. barangay health workers, traditional birth → These patients shall be referred to the most skilled source of medicinal and hospital care.
attendants) that typically comprise the Community Health Team (CHT). This team implements the MNCHN → As a first choice they will be referred if at all possible for continuing care or consultation.
Core Package of Services identified for the community level. → Second choice will be followed carefully by the rural health unit, city health clinic/puericulture center
→ All RHUs and BHS should have a master list of pregnant women in their respective catchment center.
COMPREHENSIVE EMERGENCY OBSTETRIC AND NEWBORN CARE (CEmONC) → The Home Based Mother’s Record (HBMR) shall be used when rendering prenatal care as a guide in the
- Capable facility or network of facilities that can perform the 6 signal obstetric functions for BEmONC, as well as identification of risk factors, danger signs and to be able to do appropriate measures.
provide caesarean delivery services, blood banking and transfusion services, and other highly specialized → There should be at least 3 prenatal visits following the prescribed timing:
obstetric interventions. o 1st prenatal visits should be made as early in pregnancy as possible, during the 1st trimester
- It is also capable of providing neonatal emergency interventions, which include at the minimum, the ff: o 2nd during the second trimester
1. Newborn resuscitation o 3rd and subsequent visits during the third trimester
2. Treatment of neonatal sepsis/infection o More frequent visits should be done for those at risk or with complications.
3. Oxygen support for neonates
4. Management of low birth weight or preterm newborn TETANUS TOXOID IMMUNIZATION
5. Other specialized newborn services - Neonatal tetanus is one of the public health concerns that is why it is important for pregnant women and child
bearing age women to get a tetanus toxoid immunization in order to protect them from this deadly disease.
COMPREHENSIVE EMERGENCY OBSTETRICS AND NEWBORN CARE FACILITY - A series of 2 doses of TT vaccination must be received by woman one month before delivery to protect baby
- Refers to lifesaving services for emergency maternal and newborn conditions/complications as in Basic from neonatal tetanus.
Emergency Obstetric and Newborn Care plus the provision of surgical delivery and blood bank services and - And the 3 booster shots to complete the 5 doses following the recommended schedule provides full
other specialized obstetric interventions. protection. The mother is then called as a “Fully Immunized Mother” (FIM).

CEmONC MICRONUTRIENT SUPPLEMENTATION

- Capable facility or network of facilities can be private or public secondary or tertiary hospital/s capable of - It is necessary to prevent anemia, vitamin A deficiency and other nutritional disorders.
performing caesarean operations and emergency newborn care. - Vitamin A: Dose: 10,000 IU; given a week starting on the 4th month of pregnancy.
- Ideally, a CEmONC-capable facility is less than 2 hours from the residence of priority populations or the o Do not give it before the 4th month of pregnancy because it might cause congenital problems in the baby.
referring facility. - Iron: Dose: 60 mg/400 ug tablet; Schedule: daily
- These facilities can also serve as high volume providers for intra-uterine device (IUD) and voluntary surgical
contraception (VSC) services, especially tubal ligations. It should also provide an itinerant team that will CLEAN AND SAFE DELIVERY
conduct out-reach services to remote communities. The itinerant team is typically composed of 1 physician a. Check for emergency signs - Unconscious, Vaginal bleeding, Severe abdominal bleeding, Looks very ill,
(surgeon), 1 nurse, and 1 midwife. Severe headache with visual disturbance, Severe breathing difficulty,
Fever, Severe vomiting
ESSENTIAL HEALTH SERVICES AVAILABLE IN THE HEALTH CARE FACILITIES b. Make woman very comfortable
A. ANTENATAL REGISTRATION/PRENATAL CARE: to reach all pregnant women, to give sufficient care to c. Assess the woman in labor - LMP (last menstrual period), Number of pregnancy, Start of labor pains,
ensure a healthy pregnancy and the birth of a full term healthy baby. Age/height, Danger signs of pregnancy
d. Determine the stage of labor
NORMAL PATIENTS e. Decide if the woman can safely deliver
→ Following the initial evaluation they will be given healthy instructions and counseling. f. Give supportive care throughout labor
→ This will include advice for prompt prenatal care examination. g. Monitor and manage labor
h. Monitor closely after delivery
PATIENTS WITH MILD COMPLICATIONS
NCM 33 FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING

i. Continue care for at least 2 hours

postpartum