STANDARDS OF PRACTICE FOR WOMENS HEALTH NURSE

PRACTITIONER/ MIDWIFE PRACTIONEER

Assessment of Health Status

1. Obtains and documents a relevant health history, including a
comprehensive obstetric and gynecologic history, with emphasis on genderbased differences.
2. Performs and documents complete, system, or symptom-directed physical
examinations on women including obstetric and gynecologic
conditions/needs that include, but are not limited to, pregnancy,
benign and malignant gynecologic conditions, contraception, sexually
transmitted infections, infertility, perimenopause/menopause/postmenopause
and other gender-specific illnesses.
3. Assesses for maternal and fetal well-being, high-risk pregnancies,
depression, and pregnancy/postpartum complications.
4. Assesses for disease risk factors specific to women.
5. Distinguishes female gender differences in presentation and progression
of health problems and responses to pharmacological agents and other
therapies.
6. Assesses social and physical environmental health risks, including
teratogens, that impact childbearing.
7. Assesses for evidence of domestic violence, sexual abuse, and substance
abuse.
8. Assesses issues related to sexuality.
9. Assesses parental behavior and skills and promotes smooth transition to
role changes.

28

10. Assesses selected reproductive health needs or problems in male

partners, such as sexually transmitted infections, contraception, and
infertility.
11. Assesses genetic risks and refers, as needed, for testing and counseling.
Diagnosis of Health Status
1. Diagnoses common non-gynecologic health problems and other
deviations from normal and provides management, education, or referral
when appropriate.
2. Identifies obstetrical and gynecologic deviations from normal, formulates
a diagnosis, collaborates, and/or refers as necessary.
3. Performs and interprets screening and diagnostic procedures, including,
but not limited to, pap tests,microscopy, post coital tests, and sexually
transmitted infection tests.
4. Orders screening and diagnostic procedures and interprets test results,
including, but not limited to, ultrasound, mammography, endometrial
biopsies, colposcopy, triple screen, and fetal assessment
tests, as well as age appropriate primary care screens.
5. Diagnoses acute and chronic conditions with an emphasis on
reproductive/gynecologic health, including, but not limited to, pregnancy,
sexually transmitted infections, infertility, benign and malignant
gynecologic conditions, peri- and postmenopause, and other gender-specific
conditions.
6. Recognizes the importance of specimen collection and preservation in
obtaining forensic evidence in victims of sexual assault and refers for further
evaluation.

29

7. Diagnoses selected conditions related to the male reproductive system,

such as sexually transmitted infections, contraceptive needs, and infertility
Plan of Care and Implementation of Treatment
1. Provides health promotion and disease prevention services to women
across the life cycle, taking into account age, developmental status,
disability, culture, ethnicity, sexual orientation, spiritual/religious
affiliation, and lifestyle and psychosocial issues.
2. Provides prenatal and postnatal care including, but not limited to,
maternal/fetal health, parent/infant relationships, lactation and parenting
skills.
3. Collaborates with other health care providers for management or referral
of high-risk pregnancies.
4 Provides anticipatory guidance and counseling to pregnant women and
their significant others.
5. Treats women for selected obstetric and gynecologic problems/needs,
including, but not limited to,pregnancy, common gynecologic conditions,
contraception, sexually transmitted infections, peri- and
postmenopause, and other gender specific illnesses.
6. Provides management and education for women and men in need of
family planning and fertility control.
7. Manages the treatment of sexually transmitted infections for patients and
their partners.8. Formulates and implements a plan of care for women in
violent/abusive relationships and victims of sexual assault, and considers
legal reporting guidelines.
9. Treats men with selected reproductive health needs or problems, such as
contraception and sexually transmitted infections.

30

10. Manages and/or refers for primary care conditions, including, but not
limited to, headaches, hypertension, urinary tract infections, upper
respiratory infections, and common dermatological conditions.
11. Performs primary care procedures, including, but not limited to, pap
smears, microscopy, post-coital tests, intrauterine device (IUD) insertion,
and endometrial biopsies.
12. Prescribes therapies, including medications, considering pregnancy,
lactation, sociocultural background, and financial resources.
13. Applies theories from the social sciences and humanities, as well as
natural sciences and nursing, including feminist and culturally relevant
frameworks.
14. Applies research that is women-centered and contributes to positive
change in the health of women or the health care delivered to women.
15. Facilitates access to reproductive health care services and provides
referrals that are provided in an unbiased, timely, and sensitive manner
16. Provides education and health promotion so that gender-specific
developmental events, such as
menarche, pregnancy, and menopause, remain as normative transitions.
17. Provides patient education to safeguard maternal/child health including,
but not limited to,
preconception care, preparation for childbirth, breastfeeding, and newborn
care.
18. Demonstrates effective communication skills in addressing sensitive
topics related to sexuality, risktaking behaviors, and abuse.

31

Evaluation
These competencies describe the womens health nurse practitioners role in
ensuring quality of carethrough consultation, collaboration, continuing
education, certification, and evaluation. The monitoring
function of the role is also addressed relative to monitoring ones own
practice as well as engaging in
interdisciplinary peer and systems review.
SCOPE OF PRACTICE
1. Promotes health and education to women and family
2. facilitates decision-making by women & family.
3. provides safe and effective antenatal care
Promotes health and wellbeing of pregnant woman & foetus.

Prepares woman for labour , birth & parenting.

4. provides safe & effective intrapartum care

Demonstrates understanding of physiology of labour
Demonstrates competent skill during childbirth
5. provides safe effective postnatal care
Demonstrates understanding of physiology of puerperium
Demonstrates competency skills to support women & family during
postnatal period.
6.provides safe and effective care of newborn
7. promotes safe & effective pharmacological interventions based on
evidenced based practice.
B Professional , legal, ethical practice

32

1. functions in accordance with legislative & policy guidelines relevant to

midwifery practice
2. assumes responsibility & accountability for own actions & clinical
decision making.
3. delivers care and practice of midwifery within the ethical framework &
social context.
C Professional development
1. demonstrates commitment to development to development of self.
2. demonstrates commitment to development of others & the
profession(health care policy)
ISSUES IN MIDWIFERY /WOMEN HEALTH PRACTIONER PRACTICE:
GENETIC TESTING:

1.Confidentiality,privacy, disclosure of information for the benefit of other

family members.
2. Limitations of testing , where confirmation of gene mutation does not
predict certinity that the condition will develop.
3. Inappropriate applications of testing such as gender selection for family
balancing purposes .
4. Potential for discrimination on basis of genetic predisposition to illness.
5. Settings boundaries to genetic application technologies in relation to
human enhancement and reproductive cloning.
6. Recognize and respect values , beliefs of people involved in decison
making.
7. Equity to access of genetic services & genomic health care.
Safety of gene therapy.
Use of DNA & its storage of DNA on forensic and other databases.

33

PROBLEMS WITH ACCEPTING CLIENTS

For a pregnant woman , choosing the right birth attendant is an

important decision requiring time and thought.
The midwife determines whether a pregnant a pregnant women is a
good candidate for natural labour & birth.
Midwife must evaluate the complications with labour.
The midwife prepares to take risks with the family s desire for a
natural birth.
LEGAL PROBLEMS

Malpractice suits.

Certain states aloow midwife to practice independently in any setting

( hospitals , homes, birth centres)

Some states allow certified nurse midwife license with the supervision
of a doctor.

Some midwives practice illegally in states without licenses to practice

the profession.

PROBLEMS WITH LABOUR COMPLICATIONS

Midwife must be quick to identify cause of the problem & how to

intervene.
If the mother requires technological intervention or need to be
transferred to hospital.
PROBLEMS WITH FINANCES

Midwives have difficulty in getting insurance reimmbursement so it

leads to facing more problems in having clients to support her practice
or collecting payment for the work done

34

 Perinatal nurses provide care to women with high risk pregnancies as

well as premature newborns or newborns with congenital
abnormalities.
Midwife monitors mother for signs of postpartum depression.
Discovering unborn child to have downs syndrome and educating
parents on pregnancy termination..
Use of DNR protocol for critically ill patients.
PROBLEMS WITH DEFECTIVE EQUIPMENT & NEGLIGENCE

An infant suffering cardiac arrest during surgery and required mechanical

ventilation as the infant had seizures .the nurse failed to notice poor air
exchange in mechanical ventilator tubings that resulted in infant suffering
from permanent neurological damage .the court held the injury to baby
occurred due to negligence of hospital employees and defective equipment
used in ICU
MEDICAL TERMINATION OF PREGNANCY

Professional development within abortion service

Employers must ensure that role, purpose and responsibilities are clearly
specified. Individuals should ensure that they identify the professional
competencies, additional knowledge and skills they will need, and that
they have access to appropriate education, training,Competency assessment
and continuing support/supervision. Once they have achieved competency,
nurses should be able to practise within agreed protocols and under the
guidance of a registered medical practitioner (DH, 1999).
Examples of role development to date may include:
_ performing a pregnancy test and communicating the results to the woman

35

_ pre-admission assessment
_ pre- and post-abortion counselling
_ participation in the process of obtaining consent for abortion procedures
_ administration of abortificient drugs (within the
context of RCN )
_ vaginal and speculum examination
_ screening or testing for sexually transmitted infections
_ ultrasound assessment of gestational age, implantation site and viability
_ insertion of osmotic cervical dilators such as Dilapan
_ assessment and provision of contraception via nurse independent
prescribing or patient group directions
_ discharge following medical and surgical procedures
_ ability to make an assessment and take appropriate action based upon the
assessment framework for children in need and use of domestic abuse
pathways
_ provision of care for the mature minor/vulnerable woman
_ leading on service and practice development
_ developing political awareness, advocacy and influencing skills.
To develop such roles, nurses need:
_ to be accountable for their own practice
_ to identify a medical champion who shares the vision and supervises and
supports the nursing team
_ a sound knowledge base and be appropriately educated and trained. (This
may include undertaking an accredited training course e.g.sonography,
counselling, Practice of Family Planning and Sexual Health course, Faculty
of Sexual and Reproductive Health (FSRH) abortion modules)
36

_ up-to-date knowledge of evidence based practice

_ robust competency assessment ensuring confidence
in performing practical skills (e.g. pelvic
examination)
_ understanding and implementation of the principles
of risk
_ opportunities to develop and practice leadership, mentoring and
supervisory skills
_ thorough working knowledge of the law on abortion
Nurses will be working lawfully in the limits of the Abortion Act 1967
providing they are carrying out treatment in accordance with delegated
instructions from a registered medical practitioner. The medical
practitioner must remain responsible for patient care throughout any
treatment ([RCN v DHSS [1981]
Legal considerations
It is critical for nurses to have a sound understanding of the legislation: it is
the provisions of the Abortion Act that make some abortions lawful only
in certain circumstances.
Essentially, authorisation for any abortion can only take place when two
registered medical practitioners are of the opinion formed in good faith that
one of the grounds for a lawful abortion exists this is a critical
element under s.1 (1) Abortion Act 1967. The legislation does not give any
scope for nurses to be signatories on the form, known as HSA1, which
confirms that the terms of the Abortion Act 1967 have been met.
Nurses do have legal authority to be involved in activity
37

that induces an abortion, as long as a registered medical practitioner is on

call and responsible for the care of the woman throughout the abortion. This
clarification of s.1(1) Abortion Act 1967 was set out in the House of
Lords case RCN v DHSS [1981] 1 All ER 545.
Conscientious objection
The Abortion Act 1967 provides a right of conscientious objection in
participate in an abortion. This right is limited only to the active
participation in an abortion where there is no emergency with regard to the
physical or mental health of the pregnant woman. More information about
this is provided in the Nursing and Midwifery Council advice sheet .
Conscientious Objection (NMC, 2006b). Nurses
who have a conscientious objection must inform their employer at the
earliest opportunity. Nurses cannot refuse to provide nursing care for these
women.
What nurses cannot do within the current legislation:
_ sign the Abortion Act forms (HSA1 and HSA4)
_ prescribe the abortificient drugs for use in medical abortions or to prime
the cervix prior to surgical abortion
_ provide abortion services alone without a doctor being on call and
remaining responsible for the woman
_ perform surgical abortions.
The penalties for any person in failing to follow the
provisions of the Abortion Act are criminal. Vicarious
liability (the principle whereby an employer is held
responsible for the acts or omissions of its employees) is

38

not engaged as this is not a matter of negligence, but of

a criminal act. RCN indemnity insurance does not
provide cover for nurses who are prosecuted for
unlawful activity.
Consent
All women undergoing an abortion procedure need to sign a written consent
form. The consent form should include:
_ the procedure to be undertaken
_ the potential complications that could occur as result of the procedure
_ any other procedures that might need to be undertaken as a result of
complications occurring.
In England, Wales and Northern Ireland, young women aged 16 and 17 years
of age are presumed to be competent to give consent under the provisions of
the Family Law Reform Act 1969. The legislation is slightly
different in Scotland where adulthood has now been defined at 16 years not
18 years (Age of Legal Capacity (Scotland) Act, 1991).
In all UK countries, young people under 16 years of age can give consent if
they fully understand what is involved parental involvement is not a legal
requirement, although ideally nurses should encourage the young woman to
involve a parent or guardian (DH, 2001b; RCOG, 2004).
Lord Frasers legal criteria for contraceptive advice:
A doctor [now taken to include other health care professionals] is justified in
proceeding with treatment on a young person under the age of 16, including
abortion, without the parent or guardians consent or knowledge if:
_ the young person understands the advice being
39

given
_ the clinician cannot persuade the young person to involve parents/carers or
allow the clinician to do so on their behalf
_ it is likely the young person will begin or to continue having sexual
intercourse with, or without, contraceptive advice
_ unless he/she receives contraceptive advice or treatment their physical or
mental health, or both, are likely to suffer
_ the young persons best interests require contraceptive advice, treatment,
or supplies to be given without parental consent.
-All women (including those under 16 years of age) seeking an abortion
have a right to confidentiality from all health care and ancillary staff. Only
in exceptional circumstances (for example, where the health, welfare or
safety of the woman, a minor or other people is at risk)
should a third party be informed (RCOG, 2004b).

Pre-abortion assessment the nursing role

The role of pre-abortion assessment is holistic and multi-faceted. It should
include:
1. Developing a full picture of the circumstances leading up to the womans
request for an abortion
The womanshould be offered pregnancy counselling if required
2. A detailed medical assessment to include:
_ date of last menstrual period (LMP) and menstrual
history
_ past gynaecological, obstetric history and sexual
health history

40

_ past and current medical history

_ current medication
_ awareness of any allergies including assessment of contraindications to
abortificient drugs
_ use of substances such as nicotine/ alcohol/ recreational drugs.
3. Physical assessment to include:
_ confirmation of pregnancy by urine pregnancy test
_ assessment of gestational age, ideally by ultrasound
scan otherwise by bi-manual examination (RCOG, 2004b)
_ prevention of post-abortion sepsis ideally services should offer screening
for chlamydia and gonorrhoea (either via urine, endo-cervical swabs or
self obtained swabs). Currently not all areas offer screening for gonorrhoea.
As a minimum standard all women should be given antibiotic prophylaxis
(RCOG, 2004b). Good practice would suggest links to local Genito Urinary
Medicine services are in place to allow partner notification when a positive
result occurs (MedFASH 2005, SIGN 2000, Welsh
Assembly Government 2006, QIS 2008)
_ obtaining blood for haemoglobin concentration/ studies, blood group and
rhesus status.
4. Referral for medical assessment as appropriate.
5. Explanation of methods of abortion which are available dependent upon
gestational age and local policy. This should include a full explanation of the
risk of potential complications (including local risk percentages). Written
information should be available.

41

6. Obtain consent for chosen procedure including assessment of competence

to consent in the case of a child under 16 years of age.
7. Assessment and discussion of future contraceptive needs to include all
available methods, and promotion of commencing contraception at the time
of abortion or immediately afterwards.
8. Appropriate and speedy referral to other agencies as appropriate.
9. Ensure medical assessment has been completed
(signed HSA1 form and drugs prescribed) before
any treatment is commenced.

42