Long-term antepartum care in the hospital
Care of the antepartum patient that's on your unit for an extended length of time can be a huge challenge, both for staff and for the patient. These are women who, for whatever reason have a pregnancy complication that cannot be managed on an outpatient basis. Diagnoses can range from preterm labor to premature rupture of membranes to placenta previa to high-order multiple pregnancy to hyperemesis gravidarum, and anything else you could imagine.
The challenges are numerous. To begin with, the woman is facing something that is (in most cases) completely unexpected. They are trying to cope emotionally with an unexpected pregnancy complication - it's a pretty fair assumption to make that most women don't get pregnant expecting to have to stay in the hospital for weeks or even months. Apart from that is the worry that things at home may fall apart - bills still need to be paid, house and cars still need to be maintained, and there may be child care issues if this is not a first pregnancy. Being that most high-risk antepartum units are housed in bigger teaching hospitals, the woman's family may live far away, and support in the form of visitors may be minimal.
The woman almost completely loses control of her schedule and her personal space. Meals are brought on the hospital's schedule, there are physician rounds, nurses coming in and out of the room, and the woman may be awakened in the night for assessment. I have had many many patients express a huge sense of frustration at this - they are already asleep at night when someone comes in to assess them and monitor the baby. They are hungry at times other than meals, or they're not hungry when the meal comes. They lose privacy, as we are always asking them when the last time was they peed, pooped, or ate, or if they're bleeding vaginally. Some women deal better with this than others, but nearly all have expressed to me that it's difficult no matter what.
I've not had a patient yet that is not concerned for the welfare of the baby that she's carrying. It's been my experience that most women on our inpatient unit will deliver their babies early and the baby will stay in intensive care (NICU) for at least some time. Since there is not really much to do but sit and think and worry, it is often a challenge to these women to not overdo the worrying. This is their baby, after all. We schedule a visit to the NICU if the woman is stable enough to ride in a wheelchair to visit, or at the very least a neonatologist comes to her room to talk with her about what to expect once baby is born.
Finally, these women are often bored completely out of their minds. They are often on bedrest with bathroom privileges, stuck in the same hospital room for weeks or months, and watching TV is not everyone's idea of fun. It is especially difficult for women who are used to being active on a daily basis.
So can we as nurses do to make these women's lives easier? In my nursing practice and at my facility, there are several things we do. First, we try to give these women as much control over her schedule as possible. Yes, we may have to perform NSTs a certain number of times in a day, but we try to work around the woman's preferences. I work 12-hour night shifts, and if a woman has to have q4 hour temperatures, I ask them to call me when they get up to go to the bathroom. I've not had a pregnant patient yet who does not get up in the middle of the night to go to the bathroom! This works pretty nicely.
If a patient has been stable for a while (exact length of time depends on the patient and her condition), the nurses may ask the doc if we can back off on certain things - like taking the woman's temp at 0400. We may also ask if she can have a 30-min wheelchair ride per day so she can perhaps go outside and get some fresh air.
We try to let patients make their room as much like their home as we reasonably can. If they want to keep snacks, or their laptop, or books, or a white noise machine in their room, we let them. We encourage visitors. We encourage a support person to stay the night with the woman, whether that is a husband, friend, or other loved one. There is a notable difference in the moods of women who have family support versus those who don't; really, that should come as no surprise.
As well, we do our best to encourage these women to talk - whether about their families, about their concerns or just about the weather. It is so vital for these women to have human contact that may or may not revolve around their pregnancy. They may just want to be themselves and NOT talk about it for a change. Or they may want to ask more questions about the pregnancy, the baby, what to expect after delivery, or what to expect once baby is in the NICU. Having a human connection is so vital to these women. I find it a joy most days to meet their needs at such a critical time in their lives.
What does your hospital do, or what do you do personally for the antepartum women in your care?
About Elvish, BSN, RN Guide
Elvish has 'a few' year(s) of experience and specializes in 'Community, OB, Nursery'. From '221B'; 37 Years Old; Joined Nov '06; Posts: 20,437; Likes: 22,631.Dec 30, '08 by jillianraeMy hospital is pretty good about giving these women some of their own time. We have one now that takes a nightly walk (she's stable) and we go by her nightly schedule. No vitals from 2300 to 0500 and the docs try to get most of the women to Q4hr monitoring when possible. We have wi-fi and all the rooms just got DVD players installed. Still only basic TV 13 channels ha ha. You can hear the frustration in their voices sometimes and we think they are being difficult or nasty or particular, but really they are trying to hold onto some sort of independence in a world where we have taken it away.Dec 30, '08 by Elvish, BSN, RN GuideI love the way you phrased that last bit, jillianrae. It is so very true. We currently have one who constantly complains about how bored she is and how she hates the food. It kind of grated on my nerves until I realized that if I had to be hospitalized for as long as she has been, those would be my two biggest complaints too. Puts things in perspective!Jan 1, '09 by southlady_1We do all of the above suggestions.......plus encourage video games, DVD players, etc. Our hospital has WiFI which helps. Having been on bedrest with my past pregnancy, I can appreciate that it is a difficult situation when we take all control away. I encourage pts to journal......it seems to help a lot. No one may ever read it but it is interesting how when I mention how journaling helped me to get rid of a lot of anger, guilt, grief, and fear, they are all doing it within a few hours. Also, I encourage them to put together photo albums,etc. Bear in mind that Magnesium as well as some other meds may make it harder to focus enough to read......audio books are another great source. I use these when I'm painting murals etc.Jan 2, '09 by Elvish, BSN, RN GuideAwesome ideas, southlady!!!! Had not thought of audiobooks but it makes perfect sense. And journaling, perfect nonstressful way to get thoughts on paper.Jan 4, '09 by mollyaquaThis thread is exactly what I was looking for when I logged in tonight. Our long term antepartum population has grown steadily over the last year, largely due to the now oft diagnosed "shortened cervix" and the greatly increased number of multiples. We have some nurses who have really taken on the mission of coming up with new ideas for meeting the physical, emotional and practical needs of thisl group of women. We have initiated an "All About Me" sort of poster that includes notes about the patient's family, with photos of her children, extended family and pets. She can divulge as much as she wishes on this poster. The unit has also instituted a scrapbook that is shared with antepartum patients. Patients that wish to share their story with future patients are invited to create scrapbook pages to add to the book after they are discharged. Journaling excerpts are wonderful gifts to share with the next mom admitted with a high risk pregnancy.
I've taught a couple of our long term moms how to knit a simple baby blanket, and a few of the moms have also made up baby hats for the unit to use with stockinette and yarn ties. Some moms become very quiet and withdrawn, and some are just so lonely. Each one handles the confinement in her own way, and the nurses challenge is to ease the stress as best we can.
We have nurses that are trained in Healing Touch that visit our patients on a regular basis. One nurse even helps with manicures and pedicures, and helps patients arrange for hairdressers to come in for a quick cut and style.
I would love to hear what is happening on your unit. Are you providing PT or OT visits for your patients on long term bedrest? Does anyone have some sort of option for massage therapy? Do you have any lists or suggestions for online resources for antepartum mothers? Maybe we could start a list of online resources...some directly pregnancy related and some simply diversional. Freerice.com and Boxerjam.com are two that come to mind.
I look forward to hearing what you are doing at your facility!Jan 4, '09 by Elvish, BSN, RN GuideWe kind of have to be proactive in reminding the docs to order PT/OT consults for longterm bedresters but they do get it. They get deep breathing & other simple exercises they can do in the bed, sometimes they will get special mattresses, it just depends.Jan 6, '09 by Daisy DoodleI want to first thank all of you Antepartum Nurses. I am a NICU nurse that required two months of inpatient care in our antepartum unit. I can't tell you how hard being on bedrest was. In the end we were blessed with healthy twin boys born at 32 weeks. From my experience my nursing practice will change. JillianeRae hit the nail on the head. I felt a complete loss of independence. I was air-evaced from our small town up to the University Hospital. I was without my family and my belongings. I was so scared, mind you I am a Nurse I understand how these things go. I knew what to expect.
The early morning visits from Doctors, Interns, Residents, and students became very difficult. The problem was that they all come in at different times. They dont read the charts, dont identify themselves and freely give diagnosis and orders without consulting eachother. My nurses stepped in and limited and coordinated the visits. In one day I had 27 different people come into my room in on 24 hour period.
The other important point is PLEASE make sure that Physical Therapy is consulted. I became so swollen ( Renal failure) that I had no range of motion in my lower extremities i.e. knees and ankles. Physical thereapy came in once. The after effect now 8 weeks I had extreme muscle atrophy and muscle contractures. This has caused terrible pain, limited mobility and require physical therapy. This doesn't make new born twins any easier.
I went from an indepent busy person to completely dependent. I looked forward to my nurses coming in. I looked forward to their company and their support. It is so appreciated. We (patients) might complain about the food or lack of entertainment, but can you imagine eating hospital food 24/7 for 2 months. A few nurses would bring in something different for me from time to time and this meant so much.
Because my husband could only come up on the weekends I needed my nurses to help get my through. They provided more that just "nursing" care. I really felt that they cared about me and my boys. Thank you!Jan 6, '09 by Elvish, BSN, RN GuideThank you for reminding us what it is like on the other side, DaisyDoodle. I am glad you made it to 32 weeks w/ your boys. You share a great amount of perspective. Thanks.Jun 3, '14 by tsclarkHi Elvish,
Thank you for your post! I am a mother of two, and the final baby was coming early (or so we thought). I ended up in the hospital's L&D unit for 50 days! Then I went home for 33 days and gave birth to my baby girl when she was 36 weeks, 6 days. It was rough. I have a healthy baby and I feel fortunate for that. However, I also have residual stress, what to me feels like a post traumatic stress disorder from feeling like I was hanging over a cliff for 50 days (and then another 33 days at home, which was a little easier than being in the hospital). Now that it is all said and done, when I tell professionals who are involved with women like me about what I went through, they are somewhat shocked. They ask if I ever saw a social worker (answer: nope). Did I get physical therapy (answer: nope).
So I now feel compelled to contact that hospital and try to affect some change in their antepartum unit. I know they have nurses there who previously worked for other hospitals that have lots of activities and things like physical therapy and counseling available to women on bedrest. Do you have any tips for me before I submit a letter to the manager of the L&D unit? I really want them to take me seriously and not just toss out my letter thinking they have another irritated new mother on their hands. Thank you so very much!
TaraJul 23, '14 by IndyMitchell, BSNI am going to school for my ASN to BSN and I have to do a project for my capstone. My unit manager gave me the suggestion of doing something for our Antipartums. We currently have art therapy that sees them not sure how often. Just wondering what else I could start. Like speakers, activites etc.. Any suggestions would be helpful.Jul 23, '14 by tsclarkHi,
I spent 50 days as an antepartum inpatient. The art therapy is a nice thought, but um, I am here to tell you that its a waste. Any crafty thing I was forced to make (I was NOT into that at all and I knit, crochet & sew and was a music major -- it wasn't the time for that sort of thing... I could not read or do anything except pray and learn what to expect) I threw away. I do not want to be reminded of that hell. I went home for bedrest for another 33 days, but 6 months later, I still have some issues that began when I got hospitalized. If it were my husband who had to do nothing and be waited on hand and foot, he would have LOVED it. Me, I went insane -- my blood pressure is still high!
If you don't have egotistical MFM peeps, incorporate them!
So, I did write the following to the hospital, hope it helps:
June 24, 2014
Chief Executive Officer
Adventist Hinsdale Hospital
120 North Oak Street
Hinsdale, Illinois 60521
Dear Mr. CEO:
On November 7, 2013, my doc admitted me to Adventist Hinsdale Hospital (hereinafter “AHH”) due to pre-term labor (my cervix was dilated to 4 cm when my pregnancy was 26 weeks and 6 days gestational age with a bulging sac of membranes). I spent 50 days on antepartum bedrest. Thankfully, I was discharged December 27th and am happy to report that my baby was born full term in January at AHH via VBAC at 38 weeks and 6 days gestational age.
While I am in the process of recovering from this disorienting event, I have become aware of perinatal support programs that other area hospitals already have in place to support the family unit in times of perinatal crisis. The Perinatal Family Support program at NorthShore’s Evanston and Highland Park Hospitals and Northwestern’s Prentice Women’s Hospital are two local programs that stand out.
My goal in writing you is that perinatal family support, or comprehensive, ongoing, coordinated, culturally appropriate emotional support provided by professionals and/or non-professionals to families during pregnancy and up to one year after, be provided to your future perinatal (including antepartum) patients. Regardless of the outcome of pregnancy, all families anticipating a birth need the support of their families and communities during and after a pregnancy (Indiana Perinatal Network, 2007). I am an extremely independent person and when I lost all independence by being hospitalized November 7th, it transformed me. While there is no way for me to change what happened, I feel very strongly that AHH and future perinatal patients can benefit from programs that can be inexpensive to incorporate; easy to maintain; and beneficial both monetarily and from a social standpoint to patients and healthcare providers. These programs may also make AHH more competitive. In conversation, my doc mentioned that one thing he will never understand is why some women in Hinsdale and neighboring communities prefer to deliver their babies at Northwestern. I can only surmise these women choose Northwestern over AHH due to its reputation. Three programs that should be relatively easy to establish within the antepartum unit of labor and delivery are inpatient physical therapy; social support; and inpatient peer support groups.
While I was a patient, I asked my doc if it would be okay to exercise in bed. He brought me some weights to use. While I am grateful, I have also endured three different physical therapy courses for a different issue in my past and am aware of how much harm can come to a person who is not instructed or performing physical therapy the correct way. As I was on hospital bedrest for cervical dilation, I was very wary of performing any exercises that may strain my abdominal muscles or affect my condition negatively. It says on your website that you have inpatient physical therapy services, and it would have benefitted me to have (even one) physical therapist visit just to show me what I could and could not do. I have insurance which would have covered the expense. Once I left your establishment, I had a very difficult time with the simplest of physical activities. Other hospitals incorporate physical therapy into the care of patients like me. Northwestern’s Prentice Women’s Hospital has a program and Edward Hospital, in Naperville, has an online video of exercises that may be appropriate for patients at the following link: Antepartum Unit Naperville, Illinois (IL) - Edward Hospital and Health Services.
As stated in Perinatal Family Support Consensus Statement published by Indiana Perinatal Network in April 2007:
“The process of maternal role attainment during pregnancy (maternal identity) was fairly well researched over the past several decades, in particular by Reva Rubin, RN, PhD and Ramona T. Mercer, RN, PhD. Rubin outlines four tasks of a mother during pregnancy: 'Seeking safe passage, ensuring acceptance of her child, binding-in to her unborn child and learning to give of herself' (Rubin, 1967, 1977; Mercer 1981). This developmental and interactional process occurs over time as the mother becomes attached to her unborn child. The ability of the woman to move through these stages depends on factors such as personality, self esteem, cultural beliefs, support systems, health, anxiety, etc. Several factors can enhance maternal-fetal attachment including fetal movement, hearing the fetal heartbeat and viewing the fetus via ultrasound.
A review of the literal reveals that women may not easily or successfully move through these tasks for a variety of reasons. The 'normal' process of maternal role attainment may be disrupted if a woman experiences:
- An unintended or unwanted pregnancy
- Complications during pregnancy, e.g. bleeding, preterm labor, diagnosis of a congenital anomaly, depression, substance abuse, domestic violence, etc.
- Pregnancy after a previous high-risk pregnancy or perinatal loss, e.g. miscarriage, termination, still birth or infant death (Armstrong, 2004).
Subsequent to any of these experiences, women and their partners may experience anxiety, guilt, fear or denial. They might avoid investing in the fetus and developing an attachment for fear of a poor pregnancy outcome or infant loss (Cote-Arsenault, 2001; Reid, 2000). Women may be less motivated to comply with medical care until the baby reaches the age of viability. In addition, the treatment plan for many high risk conditions can challenge women and their families. For example, treatment for preterm labor (and several high risk conditions) is often extended bed rest for weeks or even months. Findings support the need for health care providers to assess these women for specific concerns throughout the pregnancy and provide ongoing education, support and resources (Kemp & Hatmaker, 1993). Women may also be nervous or anxious about becoming pregnant following a perinatal crisis. Contemplating pregnancy following an infant loss or the birth of a child with a chronic illness or disability can be extremely stressful for families. Preconception counseling and partner support prior to a subsequent pregnancy may be recommended. Anecdotal information from families indicates they find such parent-to-parent support reassuring and helpful.”
Labor and Delivery
Support during labor and delivery empowers families and benefits health care systems. When they find themselves in a hospital setting, parents often feel powerless and 'out of control' – particularly during a crisis. The cost benefits are clear when healthy outcomes are increased by decreasing maternal stress. Families supported by other parents experience less postpartum depression, fewer repeat visits to the doctor and report an increase in their ability to cope. Given the research, it is reasonable to assume that family support not only fulfills the mission of health care systems, it also decreases the cost of patient care as evidenced by a decrease in repeat admissions to the hospital, fewer repeat visits to the doctor and decreased lengths of stay.
Strober (2005) evaluated a program designed by 'veteran' parents to help acclimate newer parents the workings of a hospital (hierarchies, how information is communicated, etc.) and what to expect.
Although families who experience a perinatal crisis may receive some support from family, friends and healthcare providers, studies” show that parents report they are not getting enough support from these resources (Kerr & McIntosh, 2000; Blackburn & Lowe, 1986; Ritchie, et al., 1994; Kant, 1994; Kazak, 1989). . . .
“Parents state that they want more support, in particular from other parents with similar experiences” (Quittner, et al., 1990; Gibson, 1986; Havermans & Eiser, 1991; Ritchie, et al., 1994; Singer, et al., 1999).
AHH could begin providing similar family perinatal support. It would require some resources, but the reputation of AHH may be positively affected. Another hospital, Stanford Children’s Health, in Palo Alto, California, has “parent mentors” who they say . . . “[a]re available to visit expectant mothers at the bedside to provide support, validation and information about the antepartum experience. Mentoring sessions vary in length and can be one-time visits or regular meetings during your hospital stay. Our Antepartum Unit parent mentors spent time as patients in the unit during their own pregnancies, and are a great resource for expectant mothers and new parents” (Antepartum Care - Stanford Children's Health). (If you incorporate something akin to the parent mentor program, please know I would be pleased to be a volunteer.)
And, The Women’s Hospital of Texas, in Houston, Texas, has a social support group they call “tea timers.” They say “The Tea Timers provides a wonderful reprieve from the stress of high-risk pregnancy and meets once a week for mother-infant education classes on breastfeeding, infant CPR, scrapbooking sessions and special holiday-related festivities” (http://womanshospital.com/our-services/antepartum.dot).
I had the pleasure of being cared for by some outstanding labor and delivery nurses. During my stay, a nurse in the labor and delivery unit, who was hired sometime in December 2013, informed me she quit her position with Northwestern Memorial Hospital’s Prentice Women’s Hospital and began working at AHH to be closer to home and spend more time with her young child. She spoke of how she worked with a great deal of antepartum women and how Prentice has physical therapy; group meetings for patients with wheelchair privileges (with doctor approval); and other amenities that impact perinatal patients positively. As you already employ her, it may behoove your organization to utilize her experience and expertise while setting up perinatal programs.
I came back to AHH to give birth in January 2014. While there, I met with a social worker. This indicates to me that social workers are already on the scene at AHH. While it may cost AHH to include social workers as counselors to perinatal patients, it also may lower costs.
Going through this transformative ordeal has impacted me and my family in ways I would never have imagined. Almost six months after my ordeal, I deal with days where I feel as though the only thing I think or talk about is “the hospital” or “the doctor.” I still have dreams about 900 gram babies. And I am dealing with physical issues as well (for instance, an odd, chronic migraine that was just diagnosed yesterday (because it stumped many doctors), which started back when I was first hospitalized). For me, talking with other women who have experienced a perinatal crisis is very beneficial to my overall health. With that in mind, I am sure you will not be surprised to find that you probably have a large number of volunteers at your service – that is, former patients who were hospitalized at AHH for a perinatal crisis. After experiencing this life-changing event, many former patients may be inclined to support others. I would love to make a difference in the life of a woman who is experiencing a perinatal crisis. It would make me feel better to know that I can make a difference for someone else. If you establish any of these or other programs, and need volunteers, please do not hesitate to contact me via e-mail at email@example.com. I would be honored to volunteer.
It was not easy for me to be on bedrest. Having great support from AHH and my doc helped me survive it and I hope that future perinatal patients will be able to experience the above-mentioned recommendations to enhance their quality of care.
Armstrong D and M. Hutti. 1998. “Pregnancy After Perinatal Loss: The Relationship Between Anxiety and Prenatal Attachment.” Journal of Obstetric, Gynecologic, and Neonatal Nursing 27: 183-198.
Blackburn S. and L. Lowe, “Impact of an Infant’s Premature Birth on the Grandparents and Parents,”Journal of Obstetric,Gynecologic, and Neonatal Nursing(Vol.15 no.2, 1986), 173-178.
Cote-Arsenault, D., D. Bidlack, and A. Humm, “Women’s Emotions and Concerns During Pregnancy Following Perinatal Loss,” American Journal of Maternal and Child Nursing (2001), Vol. 26 no. 3, 128-134.
Dunst,, C.J., C. M. Trivette and A. G. Deal, Enabling and Empowering Families (Cambridge: Brookline Books 1999).
Gibson, C.H. “How Parents Cope with a Child with Cystic Fibrosis,” Nursing Papers (Vol. 18, 1986), 31-45.
Havermans, T. and C. Eiser, “Mother’s Perceptions of Parenting a Child with Spina Bifida,” Child: Care, Health and Development (Vol. 17 no. 4, 1991), 259-273.
Indiana Perinatal Network, “Perinatal Family Support Consensus,” April 2007. http://c.ymcdn.com/sites/www.indiana...ort_042007.pdf
Kant, R.V. “An Analysis of Caregiving Work,”Australian Journal of Marriage and Family(No. 15, 1994) 66-75.
Kazak, A.E.“Families of Chronically Ill Children: A Systems and Social-Ecological Model of Adaptation and Challenge,”Journal ofConsulting and Clinical Psychology(1989) Vol.57 no.1, 25-30.
Kemp, V.H. and D. D. Hatmaker, “Health Practices and Anxiety in Low-Income, High and Low-Risk Pregnant Women,” Journal of Obstetric Gynecologic and Neonatal Nursing (1993) Vol.22 no.3, 266-272.
Kerr, S.M. and J. B. McIntosh, J. B. “Coping when a Child has a Disability: Exploring the Impact of Parent-to-Parent Support,”Child: Care, Health, and Development(Vol. 26, No. 4, 2000), 309-322.
Quittner, A.L., R. L. Glueckauf and D. N. Jackson, “Chronic Parenting Stress: Moderating and Mediating Effects of Social Support,” Journal of Personality and Social Psychology (1990) Vol.59 no.6, 1266-1278.
Reid, T., “Maternal Identity in Preterm Birth,” Journal of Child Health Care (2000), Spring Vol. 4 no.1, 23-29.
Ritchie, J.A., M. J. Stewart, P. McGrath, D. Thompson and B. Bruce, “Support and Burden Experienced by Mothers of Chronically IllChildren,” final report submitted to the Hospital for Sick Children Foundation, Grant No. XG 92-024 (1994, Winnipeg, Manitoba:The Spina Bifida Association of Canada).
Singer, H.S., J. Marquis, L. Powers, L. Blanchard, N. Divenere, B. G. Ainbinder and M. Sharp. 1999. “A Multi-Site Evaluation of Parent-to-Parent Programs for Parents of Children with Disabilities.” Journal of Early Intervention 22(3): 217-229.
Strober, E., “Is Power-Sharing Possible? Using empowerment Evaluaton with Parents and Nurses in a Pediatric Hospital,” Human Organization (Summer 2005)
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