Perinatal Nursing

Perinatal Nursing in Canada

• Provides care from pre-conceptions, pregnancy, birth (both mother & newborn), to 3 months postpartum

Defining Risk in Perinatal Nursing

• Pregnancy & birth are considered normal & health (not risk)

• Typically done through scoring but is typically challenging & unreliable due to accuracy of scoring

• Defining normal & high risk should be based on context of situation

Challenges associated with determination of risk

• Complications are varied: can be related to pregnancy or known/unknown pre-existing medical condition

• Complications can occur at varying times during pregnancy & postpartum

  • ie: HTN or cardiac complications

• Classifications can lead to unnecessary interventions such as fetal monitoring or bed rest

• Can be difficult to discern abnormal symptoms based on the pretext it is normal with the risk situation

Low vs high vs complex high risk

• Low risk

  • has predictable psycho-social & perinatal/medical health & outcomes

  • I.e.: stable mental & physical health

  • Pregnancy health on normal trajectory

• High risk

  • has predictable psych-social, unpredictable perinatal & predictable medical health & outcomes

  • i.e: stable mental health / past Hx addictions or violence + stable medical conditions such as lupus or diabetes + common pregnancy complication such as gestational HTN, PPROM, or preeclampsia

• Complex high risk

  • has unpredictable psycho-social & perinatal/medical health & outcome

  • i.e: current addiction/methadone or current family violence or unstable mental health or potential lethal fetal anomalies + acute medical condition such as Acute RF or active lupus + complicated pregnancy complications such as PPROM < 26 weeks or unstable twin-twin transfusion + unique medical interventions/complications

Parental Transition challenges & Supports for Low, High & Complex Risk

• Low risk:

  • Predictable parenting challenges & needs

    • High independence in self-care & self-efficacy

  • Usually self-directed in meeting needs

  • Can offer community prenatal education to support self-directed learning

  • Best practice/theoretical approaches to teaching & learning to meet group/individual needs

• High Risk

  • Potential for parenting transition challenges

    • Low-mod risk for prenatal attachment issues

    • Moderate independence in self-care & self-efficacy

  • Anticipatory guidance important

  • Offer community prenatal education, parenting programs based on needs (postpartum experiences or breastfeeding)

  • Best practice/theoretical approaches to teaching & learning to meet group/individual needs

• Complex High Risk

  • Potential for significant parenting transition challenges with unpredictable course

    • High risk for prenatal attachment issues

    • Low-moderate independence in self-care & self-efficacy

  • Will need individualized learning & teaching approaches

  • practice/theoretical approaches to teaching & learning may not meet needs

Problems with Antenatal Risk Scoring

• Accurately predicting obstetric complications is impossible

• Only accurately predicts complications in less than 7% women

• No evidence suggest risk-assessment tools improve maternal & neonatal outcomes

• Women classified as “at risk” or “high risk” can lead to more routine or unnecessary interventions that are appropriate or effective.

• Sometimes risk scoring can lead to stigmatizations of women & impose stereotypical adverse set of expectations that may or may not be true

  • Example: A pregnant women who is obese = high-risk pregnancy

• Risk classifications can increase anxiety or fear with unnecessary interventions or wish for greater monitoring & interventions that aren’t necessary

WHO Definition of Normal Birth

• Gestation between 37-42 weeks

• Singleton fetus

• Vertex presentation

• Spontaneous onset of labour

• Presence of skilled birth attendant

WHO-Euro Bologna Score

• Takes into account multiple indicators to determine whether labour is managed as normal birth

• Women who have a caesarean birth or have induced labour are excluded

• Criteria

  • WHO original def of normal birth

    • Gestation between 37-42 seeks

    • Singleton fetus

    • Vertex presentation

    • Spontaneous onset of labour

    • Presence of skilled birth attendant

  • Presence of a companion at birth

  • No labour augmentation (mechanical or pharmacological)

  • Use of a partogram to monitor labour

  • Use of a non-supine birth position

  • Skin-to-skin contact at least 30 minutes within first hour

Canadian Definition of Natural Birth, Normal Birth, Normal Pregnancy/Labour & Normal Delivery

• Natural childbirth = involved little or no human intervention

• normal birth: excludes elective induction before 41 weeks, spinal analgesia, general anesthesia, forceps or vacuum, c-section, routine episiotomy, & continuous electronic fetal monitoring.

• normal deliver: can include interventions such as induction, augmentation, electronic fetal monitoring, artificial rupture of membrane, pharmacological pain relief

• Normal pregnancy & labour: can include complications such as HTN, antepartum or postpartum hemorrhage, perineal trauma + repair, NICU admin.

• These definitions attempt to accept commonly used current practices as “normal” and not stigmatize women who experience these procedures & interventions as abnormal

Demedicalizing Birth

• Medicalizing birth is fuelled by the idea of “at least everything possible was done to prevent a negative outcome” & “each birth has to be perfect & every available technique may be used to achieve this”

• Results in routine fetal monitoring, ultrasounds, epidural anaesthetic & c-sections.

• Common routine practices such as separation of mother-baby, suctioning of newborn at birth, supplementation with water or breastmilk substitutes, suctioning meconium-stained liquor & intubations & suctioning to prevent meconium aspiration are not evidence-informed & can impact fetal to neonatal transition

• Having a support companion & one-one nursing ratio are two very beneficial interventions in birthing process

Purpose of Family Centered Care in Maternal & Newborn Care

• Promote optimal wellbeing for mother, child & family

• Increases participation of women & families in decision making process

Principles of Family Centered Care

1. Addresses need of woman, newborn & family + supports from pregnancy-postpartum

2. Sensitive to psychological + social needs

3. Culturally sensitive & informed

4. Individualized to meet families needs

5. Respect & dignity

6. Encourage family involvement in-care of newborn despite whether infant is “sick” or “healthy”

7. Families take active role in decision making

8. families offered knowledgeable & appropriate care to support breastfeeding & alternatives when needed

9. Confidentiality

10. Thrives on feedback from families

Person Centered Care

• A care practice approach the focuses on the person as a whole

• Takes into account person’s experience of the health or life challenges

• Broader view of whole person

• Takes into account needs based on SDH

• Focus on empowerment through enhancing knowledge, competency & efficacy of self-care and decision making

• Give them a voice to share their story & actively listen

• Takes all of this in to account to guide your care

Informed Caring for the Well-being of Others

• Created by Kristen Swanson

• Theory based on perinatal nursing and developed to support women experiencing miscarriages

• Focuses on how nurses see and understand people affects who they care for and how they provide care & how it shapes the enviroment they created and the goals of nursing care

• Relationships are a central concern in nursing & include nurse-to-client, nurse-nurse & nurse-self

Swanson’s Structure of Caring

1. Maintaining Belief (esteem): sustaining faith in the others capacity to get through an event/transition & face a future with meaning

• Aligns with strength-based approach

• Having hope (not the same as false hope) & view optimism

• See the positives or strengths and how they can be harnessed to move forward

2. Knowing (Empathetic Understanding): striving to understand an event as it has meaning in the life of the other.

• Striving to understand an event as it has meaning in the life of the other

• Arises from nurses knowledge of emotional, psychosocial, spiritual & cultural aspects of health & wellness as they relate to the others experiences or realities & their responses

• Do not make assumptions of Judgements

3. Being With (Emotionally Present)

• Be present & share in the meaning & feelings of others (not the nurses) reality

• Convey availability: communicate they are not alone & we are here, attentiveness, physical presence (sometimes in silence)

• Sharing feelings

• Not burdening

4. Doing for (Enact for)

• Doing for the others he/she would do for oneself if able

• Protect dignity

5. Enabling (Empowering)

• Enable self-care & self-healing even as you do for them

• Provide resources & needed information

Prenatal Factors Affecting Transition to Motherhood

• Adverse childhood experiences

• Presence or absence of a support network

• Difficult labor

• Complication postpartum

• Neonatal hospitalization

• Past losses and mischarges

• IVF

• substance use

• High risk pregnancies

Process of Transitioning to Motherhood

• Engagement with maternal task is primary process facilitating transition to Motherhood

• Engagement enables the secondary process of growth & rransition

• Women often have unrealistic expectations of post-partum period

  • Inform it is normal to feel overwhelmed, uncertain & experience physical & mental exhaustion during first couple of month.

Social Discourse of Motherhood

• Mothering is a social experience that is shaped by society’s structures

• Due to this the social discourse of motherhood impacts women’s health

• Mothering requires material, economic & social investments that are not usually economically compensated for

  • Ties into societal expectations of women to care for family and household without compensation

• Mothering women are more vulnerable to health risk especially those with overwhelmed workloads, poverty & violence

Forms of Mothering that Do Not Fit Normative Social Discourse of Motherhood

• Step mothering

• mothering in lesbian couple, gay couple & transgender persons

• Surrogate mothers

• Mothering by very young women

• Mother within a communal house-hold

• Grandmothers as primary caregivers

• Non-custodial mothering: foster mother

• Single mom

• Normal = biological & two-parent family

Preconceptual Health Interventions

• any interventions that identifies and modifies any risk to male or female reproductive health or pregnancies

Reasons for Preconception Care

• Critical developing period of fetus is before women know they are pregnant.

• Modifiable or treatable preexisting comorbid conditions such as diabetes, substance use, etc. are linked to adverse perinatal & maternal outcomes

• Exposures to toxins can negatively impact fetus

Barriers to Preconception Care

• Pre-conception care not routinely being sought out (economic, access, marginalization’s)

• Pre-conception care only for those who planned pregnancy

• Challenges to provide health educations across diverse populations

• Clinicians not being confident or knowledgeable in need for preconception care

How many pregnancies are unplanned?

½ of all pregnancies are unplanned

Integrated Psycho-Social-Medical Model During Pregnancy

• Traditional guidelines for antenatal care emphasize clinical assessment but often over look psycho-social aspects of pregnancy

• Studies found woman values psychological & social support as much or more than clinical care

  • Psychological supports: reasonable wait times, unhurried visit, continuity of care & caregiver, flexibility, comprehensive care, meeting with other pregnant women in groups & develop loving relationships with professions

• Women need information not just on common discomforts of pregnancy but also warning signs indicating need for professional

• View pregnant women & families as active partners in care

• Provide adequate resources to prepare for child such as birthing classes

  • Prenatal classes are often under attended

Integrated Psycho-Social-Medical Model During Labor & Birth

• Women & birthing families often report clinical birth environment stressful: quiet, gentle, supportive, & encouraging environment

• Encourage skin-to-skin contact

• Don’t separate mother & baby

• Breastfeed when baby shows signs of readiness in a quiet environment

• Encourage siblings to share in the birthing experiences

Indigenous Care

• Evacuation of women for childbirth often w/o a support person to hospitals far away is common in remote communities

• Community-based Indigenous midwives with an integrated approach of traditional & modern ways are ideal model

• Need culture-based prenatal outreach & support programs

Ways to Optimizing Preconception Health

• Encouraging women to access preconception health resources

• Clinicians taking advantage of episodic visits to identify health risk & offer interventions & encourage positive healthy behaviours prior to conception

• Encourage all women & men of reproductive age to develop a reproductive-life plan

• Recommend folic acid to all women

• Immunizations up-to-date

• Review medications for potential teratogenicity & counsel women on impacts to pregnancy regardless of plans to conceive.

• Promote smoking cessation & screen for drug & alcohol use

• Encourage progress towards healthy weights

• Screen for STI or STI risk factors

• Optimize chronic medical conditions to improve perinatal & maternal outcomes

• Educate on interpregnancy interval for women who have previously given birth

Cultural Dimensions of Pregnancy, birth & Post-natal Care

• Impacts how woman perceives & prepares for birthing experience

• Different cultures have own values, beliefs & practices related to pregnancy & birth

• Some women of same culture will adhere to cultural traditional practices & some won’t

• Communication with different languages is a common barrier to providing cultural-informed care

Disclaimers on Cultural Practices & Beliefs of Pregnancy

• Terms used to distinguish cultural divergent groups need to be clarified from the perspective of the child bearing person, partner & family

  • Geographic labels often don’t define cultural uniqueness of populations living within the boarders

• Recognize the political & racial forces that guide perceptions of care provider and recipient

  • Provider: self-reflect on what is guiding your interactions

  • Recipient of care: personal & ancestral history will be a basis for their perception & engagement in care experience

Culture

• Is contextual

• Group membership doesn’t imply total subscription to group values, beliefs, attitudes or practices

• Influenced by experiences

• Avoid assuming culture solely based on race, nationality or ethnicity

  • There is a difference from culture & race, nationality & ethnicity

Rubin’s Mother & Maternal Role Attainment

• Theoretical framework of motherhood

• defines maternal role attainment as a process which the mother achieves competence in the role & integrates mothering behaviours into her established role set, so that she is comfortable with her identity as a mother”

• Three main principles

  • Relinquishment of pregnancy role & taking on role of mother is major adjustment

  • Postnatal maternal-infant role relationship is a continuation of maternal-fetal attachment relationship that started at pregnancy

  • Progression through developmental stages of new motherhood is individual

Phases of Rubins Mother /Maternal Role Attainment

1. Taking-in-phase (dependent): 1-2 days; mother self preoccupation as she recovers from delivery, dependent on support persons & caregivers for self & newborn care

2. Taking-hold phase (independent): 2/3rd day-10days/several weeks mother attempts to take back control & begins to engage with baby, initiate self care & newborn care; attachment process with baby is evident; still accepting help from others

3. Letting-go phase (interdependent): redefining her new role/relationships, lets go of old self & accepts the new normal.

Positive Influences on the Transition to the Mothering Role

• Positive quality of prenatal attachment relationship between expectant mother & unborn baby is predictive of a positive postnatal relationship

• Confidence in doing mothering task is related to a mother’s difficulty with daily routine & discrepancies between anticipated & actual maternal responsibilities

  • Example: If newborn is facing health issue or has care needs the mother is not able to independently for her baby

• Earlier a mother holds her infant after birth the sooner the postnatal relationship begins to grow

  • Attachment & bonding occurs regardless of time

Transition to Fathering

• Also requires their own postnatal bonding

  • Objective disengagement doesn’t = lack of bonding

    • Common for men to be silent or appear not involve

  • Presence of men contribute to their infant attachment

• Major transitions

  • Commitment to fathering

  • Becoming father: need to determine their own identity of fatherhood

  • Making room for baby in their own relationship with partners

  • Demands of baby & finding strategies to balance demands of work, partner & baby can lead to exhaustion, stress & confusion

    • Require social supports

• Fathering roles often include that of: provider, guide, household help & nurturer

  • Often w/o cultural references to look to on the fathering role, new dads can feel helpless, incapable, uncertainty and weak

• Stress of fathers are often related to meeting social expectation of fatherhood rather than lack or process to acquire competencies

Lesbian Mothers

• Challenges

  • Experience challenges accessing perinatal services & resources

  • Experience heteronormative, sexist, non-supportive, non-affirming & insensitive care in perinatal setting

• Rely on ART for conception = great financial cost

• Parenting rights are not automatic for the non-biological parent, so have to go through adoptive process

• May feel disenfranchised or marginalized in a hospital system due to traditional maternal & heterosexual nature

• Won’t access care b/c of fear of poor treatment & stigma

• In an attempt to normalize or not discriminate clinicians often refer to lesbian families as just another “couple”. Instead an individual approach should be taken based on perspective of persons

• A birth partner may feel ambiguity in their parenting roles as the focus is on the birth mother for care. Approaches include:

  • Assurance of desired level of partner involvement

  • Acknowledge role & significance of being a parenting partner

    • Include in conversations

    • Ask how they would like to be referred to (mom?)

Gay Fathers Pregnancy Process

• Pregnancy occurs through surrogacy

• Traditional/altruistic surrogacy: surrogate woman pregnant w/ own egg & sperm of donor or prospective father

• Gestational surrogacy: donor egg inseminated with sperm of prospective father in lab & is implanted in surrogate

• Sperm samples can be mixed to give both men a chance at being biological father

Surrogacy

• Legal in Canada

• Considered an altruistic arrangement in Canada: can’t pay mothers, only have have pay for expenses incurred

• Emotional/relational issues can arise during pregnancy between partners, families, surrogate and friends

  • Sometimes relationship with surrogate grows and can become part of the family circle

• Some surrogate can suffer separation anxiety & depression similar to mother who relinquish babies for adoption

Gay Fathers

• Requires reorientation of role & responsibilities including work, caregiving responsibilities and social life

• Tend to be more attentive & protective in parenting

• Adoption is usually necessary for non-biological father

• Integration of self-identity of father & gay man is part of fathering journey

• Can have challenges in disclosing family of origin

Transgender Men Pregnancy

• Can become pregnant if they retain functioning ovaries & uterus

• Requires stopping testosterone treatment if they have physical transitioned to male

  • Will start menstruation within 6 months of stopping

  • Testosterone should not be considered an contraceptive

  • Testosterone has to be stopped during entire pregnancy because it can harm the fetus

• Childbearning person should not be viewed in maternal context of pregnancy

  • Journey to fatherhood not motherhood

  • Identify as fathers or may prefer a different language (they)

Giving Birth In Canada Following Earlier Female Genital Mutilation

• Involves total or partial removal of female external genitalia & or other injuries to female genital organs

• Types

  • Removal of clitoral area, partial or total removal of clitoris &/or foreskin removal

  • Excision: removal of part of entire clitoris & part/all of labia minora

  • Infibulation/pharaonic circumcision: removal of medial parts of labia majora & the joining of two side of vulva with thorns, silk or catgut sutures. A small opening is created with the insertion of a foreign body to allow passage of urine & menstrual blood

    • May require to undergo gradual dilation by husband to allow sexual intercourse

    • Willl have to be cut to allow passage of baby & then re-sutured

  • Insertion of corrosive substances in vagina to facilitate “dry” sexual intercourse

• Often report

  • Doctors don’t provide kind of birthing procedures they would prefer

  • Pressured to get c0section

  • Pressured to have male companion when female birthing companion would have been preferred

  • Insensivity regarding pain management

Gender Dysphoria & Pregnancy : Transgender

• Some can become more connected with their bodies

• Some can have increase in dysphoria

  • Not being able to present as male can be challenging

  • Female hormonal changes associated with pregnancy can be distressing

Postpartum Transgender Men

• High incidence of postpartum depression

  • High incidence of feeling of isolation & loneliness during pregnancy & early period of parenthood is associated with high risk of perinatal depression

  • Exacerbation of gender dysphoria

  • Lack of gender inclusive resources

  • Lack of knowledgeable & experiences HCP

  • Referral to mental health services may be required

• Deciding when to restart testosterone therapy

Infant Feeding Transgender Men

• Language: may prefer term “chest feeding” but should ask for preference

  • Likely still retaining breast

• May use donor milk

• Referral to lactation consult might be a good idea

Risk for IPV Demographics

• Woman

• Children

• Ingenious peoples

• People w/ disabilities

• Identify as LQBT

How many homicides every year is committed by a family member in Canada?

172

How many victims of violence crimes is the person responsible a family member in Canada?

Approx 85,000

How many Canadians say they have experienced abuse before the age of 15 y.o?

1/3 or under 9 million

How many Canadians say they have experienced unhealthy spousal conflict, abuse or violence in the pas t5 years?

760,000

Challenges of Gathering Stats on IPV in Canada?

• Reluctant to talk about family violence

• Fear of their safety or children’s safety

• Depend on family member who was abusive or violent

• Feel shame, blame or denial

• Think no one will believe them, be blamed or judged or will be arrested

• Don’t want anyone to know (it’s a personal matter)

• Addressed it through other means

• Felt it was minor or not important enough

IPV During Pregnancy

• Fatal outcomes

  • homocide

  • suicide

• Non fatal outcomes

  • Negative health behaviour

    • Alcohol & drug abuse during pregnancy

    • Smoking during pregnancy

    • Delyared pernatal care

  • Reproductive health

    • low birth weight

    • Pre-term labour & delivery

    • Insufficient weight gain

    • OB complications

    • STI/HIV’s

    • miscarriage

  • Physical & mental health

    • Injury

    • Physical impairment

    • physical symptoms

    • depression

    • lack of or difficulty with attachment to child

Screening for IPV

• Should be screened during routine prenatal care & during hospital setting

• Hospital should imbed questions about abuse in healthy history or incorporate validated screening instruments into history/assessment process

• Screening should be universal: ask every person over a specific age about experiences of abuse if in a safe enviroment

• Routine screening performed on regular basis

• Indicator-based screening if nurse observes indicators of abuse

HCP Response to Disclosure of Abuse

• Acknowledge their abuse

• Validate the experience

• Assess immediate safety

• Explore options

• Refer to support services w/ person’s consent

• Document interaction

• Child protection if children is involve

Risk perception in women with high-risk pregnancies

• Risk perceptions is shaped by individual experiences & social constructs

• Risk perceptions affects decision people make about antenatal care so it can influence well-being of mother & family

• Pregnant people focus on doing research during their pregnancy to make decisions about birth. They use multiple sources of information to determine risk including advice from professional & other trusted sources & their own intuitive knowledge

  • Can also increase doubt on health of pregnancy & can lead to overreliance on expert opinions

• If women recognize the risk posed to their pregnancy, steps can be take to ensure health of themselves & baby

• Women’s perceptions of risk & the care they will accept are dependent on the context of their individual circumstances

Core principles of Perinatal care to Overcome Risk

• Person centered & family centered care

• Individualized care

• Kindness, respect & dignity

• Care is informative, respecting person's learning style, knowledge & cultural tradition

• Care is collaborative: informed-decisions, made in partnership with HCP

Tradition African Birth in South Africa

• Take place in supportive & secure environment often grandmother’s home

  • Surrounded by people she trust

  • Ancestral spirits protect her here

  • Free from polluting contacts such as mensurating women

• Move to rural to urban

  • Not in traditional environment but rather hospital

  • Traditionally woman are encouraged to remain ambulant & active in 1st stage while in hospital encouraged to rest

  • Go from lots of social support to few

  • Traditional to exclude husband

Pregnancy & Birth Related CUstoms among Indian Womem

• Have 11 sanskara (sacraments) governing conception, pregnancy, birth & early infancy

• Believe conception involved mingling of substances from both parents

• Fetus is believed to be nourished by blood transfusion from mother via fontanelle & though umbilical cord develops in last month of pregnancy

• Too much food is seen as harmful

• “Cooling” or “windy” foods are believed to threaten fetus

• Remain tranquil during pregnancy

• Supposititious beliefs are common & everyday objects can be viewed as omens

• Return to mother’s house a month before birth & isolate

• Mother & experience friends/family members tend to pregnant women

Experiences of High- Risk Pregnancy

• Range of emotional & psychological experiences

  • overwhelmed by diagnosis, hospitalization & aftermath of pregnancy

  • Individuals measure themselves against societal norms of how an pregnancy is supposed to be

  • Isolation & loneliness from family & community when hospitalized & separation from baby who requires NICU or close monitoring

  • Fear, guilt, frustration, anxiety, sadness & grief of loss of an idealized, healthy baby

• Diagnosis of high risk can impact mother post-partum into depression, PTSD, suicide, & other psychological health issue

• Experiences are influenced by

  • Negative experiences of high risk experience throughout the pregnancy & reult in a “traumatic birth”

  • Poor quality care & negative attitudes of HCP

Incidence of High-risk Pregnancy & Birth experiences has Been Increasing over Past 2-3 Decades

• Mean age of childbearing has been increasing

• Current medical interventions are able to support women w/ complex health issues through pregnancy & childbirth

• Interventions for newborn & child with congenital & chronic conditions are more effective = new population of adults experiencing high risk childbearing experiences

• This effect increases the chance of a pregnancy being complicated by coincidental medical conditions and increases the risk that such conditions can impact on women’s health and merit intervention

Bed Rest & Pregnancy COmplications

• Bed rest is not supported as an intervention for most pregnancy complications

• Results in loss of bone & muscle mass = requires PT exercise to offset as much loss as possible

• May be stressful for person, partner, & family

• Patient will need help w/ coping w/ isolation, boredom, stress & worry

• May take place in hospital or a home

Objects of Prenatal Care Following an Antenatal Diagnosis of a Pregnancy Complication

• First visit = Confirming diagnosis of pregnancy & beginning process of obtaining health Hx to act as a basis for ongoing prenatal care

• Objectives

  • Prevention of complication or modification of those complications that may develop

  • Support to meet woman’s goal to maintain pregnancy to term while meeting best health potential for mother & baby

  • Providing education to parents & family for the parenting role w/in context of health risk being faced

  • Inclusion of family to support “family-centered care”

Patient education & birth planning for high-risk pregnancy

(Questions)

• How does the effect on the pregnancy or newborn health vary that of a low risk or uncomplicated pregnancy?

• What is the prognosis for the mother & baby

• What is the level of knowledge & understanding on the part of the expectant mother, partner & family of current health issue & potential ramifications of the birth experience?

• Was the pregnancy or newborn complication anticipated pre-conceptually or is it new?

• How is the current and or anticipated experience different from the envision experience?

• What values, hopes & goals are held onto?

• What fears & challenges are currently being experienced? What might be helpful to overcome these?

Trauma & Perinatal Health

• Sources of trauma

  • adverse childhood experiences

  • IPV

  • Birth trauma

  • Sexual abuse or assault

  • previous perinatal loss

  • Mental health

• Trauma increases risk of perinatal depression, anxiety, preterm labour, LBW, & infant morbidity

• Pregnant women & infants are among the most vulnerable to lifelong intergenerational ramifications of trauma

Tokophobia

• extreme fear of childbirth

• often a result of previous trauma such as birth trauma or sexual abuse

• Parents will often oft for a c-section

Trauma Informed Care 4 Rs

• Realization/develop awareness of the widespread impact of trauma on general and perinatal health

  • Reflect on how to respond by ensuring & enabling safe care environments that acknowledge, validate, empower, build trust & invite & facilitate opportunities to have healing conversations

• Recognition of signs that a patients has been triggered while receiving care and respond within timely manner

  • Communication that is relational & patient-centered

  • Anticipatory care planning for complications or trauma

• Resources that help nurses to respond by providing trauma informed nursing care

  • Institutional care cultures for trauma-informed care & provide education & generate policies

• Resisting re-traumatization

• All concepts focus on safety, control & choice

Pregnancy & Substance Use Nursing Implications

• All substances alcohol, tobacco, benzos, marijuana, opiates can cross the placenta and impact the fetus

• Harm reduction approach = opiate agonist (methadone or buprenorphine)

• Often baby is motivation to change

• Stigma, fear, trauma & mental health concerns are major barriers to maternal engagement w/ care

• Prejudice & judgement from HCP, internalized stigma, and estrangement to families lead to isolation, late access to care, fear to disclose substance use, vulnerability & not meeting potential

• Legal concerns: implications related to parenting & custody when baby is born

• All women who use or don’t use substances all share the same aspirations & dreams. The only difference is women with substance use have more obstacles standing in their way to realize and achieve these aspirations

• Breastfeeding is supported & encouraged for babies experiencing neonatal abstinence syndrome or opiate withdrawal

Impacts of Substance use in pregnancy (mom, fetus, neonate)

• Mom: pregnancy loss, preterm labor, HTN, blood coagulation problems, placental abruption,

• Fetus: fetal grown restriction, intrauterine death, congenital defects, & developmental issues

• Neonate: Neuro behaviours symptoms (tremors, extreme irritability, inconsole cry, inability to self-soother, poor sleep, hypothermia), seizures, GI & respiratory issues

Contributing Factors to Substance Use in Pregnancy

• Hx of drug addiction, chronic pain

• Hx of psychological, physical or sexual trauma

• Hx of mental illness

• SDOH

Substance Use & Impacts on Baby

• Opioids use such as morphine, dilaudid fentanyl, methadone & buprenorphine result in neonatal abstinence syndrome

  • Buprenorphine appears to have less withdrawal symptoms that methadone but not always best choice for recovery

• Cannabis, Benzodiazepines, antidepressants/SSRI’s, nicotine & caffeine may cause withdrawal symptoms but neuro effects are different

• Cocaine & other stimulants can cause withdrawal but do not impact neurological effect

• Alcohol doesn’t cause withdrawal symptoms but can cause congenital health issues

Neonatal Abstinence Syndrome Symptoms

• Central Nervous System:

  • inconsolable high-pitch crying

  • disorganized sleep

  • irritability

  • hyperactivity deep tendon reflex

  • tremors

  • hypertonia

  • restlessness

  • seizure

• Gastro

  • poor feeding

  • frantic sucking

  • regurgitation

  • projectile vomit

  • loose & watery stools

• Autonomic dysregulation

  • sweating

  • temp

  • yawning

  • mottling

  • nasal stuffiness

  • sneezing

  • tachypnea

Neonatal Abstinence Syndrome Care & Management

• Baby & mom cared together

• skin-to-skin & kangaroo

• swaddling & soothers

• Do not require NICU unless other health issues requiring admission b/c it is a loud and active environment

• Infant assessment & scoring for risk of signs/symptoms should be done in collab with famil

Eat, Sleep, Console Tool

• Infant with NAS is regularly assessed and determined if pharmacologic treatment is required

1. Can infant eat >/= 1 ounce per feed or breastfeed well?

2. Can infant sleep >/= 1 hour?

3. Can infant be consoled within 10 minutes?

• If all answers are yes than Infant is considered to be well managed & no further intervention needed

• If any answer is no try nonpharm approach

  • Feeding on demand

  • Swaddling & holding

  • Low-stim enviroments

  • parental presence

• If nonpharm don’t work start morphine @ 0.05 mg/kg per dose every 3 hrs or increase by 0.01mg/kg per dose

Medications for Neonatal Abstinence Syndrome (NAS)

• A narcotic is used to control withdrawal symptoms

  • They are not “addicted” but physically dependent on medication

  • Short-acting opiated are used w/ babies to mediate symptoms & slowly withdraw them from narcotics

  • Typically morphine is used

• Clonidine = decrease autonomic symptoms

• Phenobarbital is rare but used when scores are not stabilizing & when weaning from meds is not going well

• Buprenorphine is being explored as a med to assist with NAS

Breast-feeding with Neonatal Abstinence Syndrome

• Baby’s withdrawal scores tend to be less w/ breastfeeding

  • unknown if r/t skin-to-skin or small amount of drugs in milk or both

• Mothers should be in encouraged to join recovery program to breastfeed

• There is concerns of breastfeeding while still on street drugs but it shouldn’t be forced to stop

• Breastfeeding is affirming to mother & evidence shows it supports & aids recovery

Pregnancy & Psychiatric Medication Nursing Implications

• Important to treat mental health concerns during pregnancy

• Not uncommon for mental health problems to initially manifest & be diagnosed during pregnancy

• Perinatal consequences of untreated mental illness in pregnancy

  • High risk for abortions

  • Broken families & homes

  • Partner problems

  • Exacerbated stress

  • Unstable work life balance

  • Other physiological co-morbid health conditions

• Depression, anxiety & PTSD often need increased support & intervention in pregnancy

  • Approach to care should be trauma informed, relational, strength-based & patient centered

Management Approachs for Mental Health in Pregnancy

• Screening, psychosocial assessment & support

  • Ideally initial screening occur in pre-conceptual

• Psychological interventions

• Pharmacological interventions

  • Weigh risk-benefits to mother & fetus

  • Doses are often adjusted

  • SSRI’s are most commonly prescribed antidepressant in pregnancy

    • Relatively safety but can mimics neural behavioral neonatal symptoms seen in neonatal abstinence syndrome

    • So do not assume mother uses substances, do an indepth hx

Obesity Risk of Complications in Pregnancy

• Prenatal

  • Gestational diabetes

  • PIH

  • Pre-eclampsia

  • Miscarriage

  • Preterm labour/birth

  • UTI

  • Decreased sensitivity of ultrasound

  • Difficulty with FHR Monitoring

  • OSA

• Intrapartum

  • Prolonged labour

  • Operative interventions

  • Perineal trauma

  • Hemorrhage

  • Anesthesia problems

  • Decreased sensitivity of ultrasound

  • FHR monitoring problems

• Postpartum

  • Postpartum hemorrhage

  • Wound infection

  • Endometritis

  • Venous thromboembolism

  • Decreased breastfeeding rates

• Fetal/Newborn

  • Congenital abnormalities

  • birth injury

  • shoulder dystocia

  • macrosomia/LGA

  • hypoglycemia

  • Fetal/neonatal demise

  • Neural tube defect

  • child/adult obesity

  • childhood/adult obesity-long term

• Long-term Comorbidities (maternal)

  • Type II diabetes

  • HTN

  • Liver disease

  • CAD

  • Ischemic stroke

  • Cancer (colon, endometrium & breast)

  • osteoarthritis

Perinatal Obesity Management

• Grounded in biomedical notions of disease causation & idea that weight is within the individuals control

• Precludes the SDOH upon which obesity is predicted

• Obese pregnant women are often stigmatized & marginalized = poor access to care and contributes to poor maternal/birthing experience

• Instead we should focus our care on being person-centered, trauma-informed, relational, strength-based & SDOH informed

Chronic HTN in Pregnancy

• HTN of any cause periconceptually or before 20 weeks gestation

Gestational HTN

• New onset HTN that develops in a previously normotensive woman after 20 weeks gestations w/o proteinuria

Preeclampsia & eclampsia

• New onset HTN after 20 weeks gestation w/

  • new onset proteinuria

  • Or in absence of proteinuria signs of multisystem involvement such as thrombocytopenia

• Preeclampsia progresses to eclampsia if seizures occur

HELLP Syndrome

• Hemolysis of RBC’s

• Elevated Liver enzymes

• Low Platelets

• Multiorgan/system syndrome that can occur in severe preeclampsia or hepatic/liver involvement

Chronic HTN w/ Superimposed Preeclamps

• Preeclampsia develops in woman w/ chronic HTN

Preeclampsia risk factors

• Pregnancy related

  • nullipariy

  • personal or family hx

  • multifetal gestation

  • IVF

• Pre-existing risk factors

  • Advance maternal age

  • Preexisting medical condition

    • Chronic HTN

    • Chronic renal disease

    • Thrombiphilia

    • Diabetes

    • Autoimmune disorder

    • Obesity

    • Antiphospholipid antibodies

Pree-clampsia Interventions/Treatment

• Delivery is the cure

• Determine optimal timing of delivery

  • At or beyond 37 weeks gestation

  • Between 34-37 weeks if preeclampsia has severe features

  • Between 20-34 weeks preeclampsia with severe features is ideally managed in a facility with maternal & neonatal intensive care resources

• Pharmacological treatment

  • Stabilize BP 140-150/90-100 mmHg

  • Labetalol = first line for

  • Adalat or Nifedipine = second line

  • Magnesium sulfate for seizure prophylaxis

Nursing Care Preclampsia

• Screen approparaitely

• Identify warning signs: severe headache, RUQ epigastric pain, nausea, visual changes, difficulty breathing & swelling in face or hands

• Ensure accurate BP measurement: proper position, cuff size & device

• Changes in body weight: more than 3-5 Ibs per week = suggestive of fluid retention

• Observe for other signs: reduced UO, edema & pulmonary edema, suggest preeclampsia associated fluid imbalance

  • Especially in second half of pregnancy

Preterm Labor

• <37 weeks

• Regular uterine contractions aren’t always detectable & present as back ache

• S&s

  • PROM

  • Cervical dilation > 2 cm

  • Effacement exceeding 50%

  • change in cervical dilation or effacement detected by serial examinations

Preterm Labour Risk Factors

• Medical

  • HTN

  • Preeclampsia

  • Thrombophilia

  • Connective tissue disorder

  • Diabetes

  • Intrahepatic cholestatis of pregnancy

• Demographic

  • Maternal age

  • low socioeconomic

  • low education

• Lifestyle

  • Alcohol/substance use

  • smoking

  • Domestic violence

  • no social supports

  • Stress

  • Occupational hazard

Signs of Preterm Labour

• Uterine contractions w/ or w/o pain or discomfort

• Feels like fetus is balling up every now & then

• Abdominal or intestinal caramping w/o diarrhea

• Pelvic pressure, low backache = dull

• Menstrual-like cramping

• change in discharge

Interventions to Prevent Preterm Labour

• Management of exisitng medical comorbidites/conditions

• Lifestyle modification

• smoking cessation

• Promotion of early & regular access to prenatal care

• Routine screeining & treatment for bacteriuria

• Teach all women on risk of pre-term birth & symptoms of preterm labour

• Early identification ensures prevention of preterm birth

  • timely transfer to facility

  • tocolytic administration to postpone labour

  • antibiotic admin for prophylaxis against infection (Group B strep)

  • Corticosteroid admin to enhance fetal lung maturity

  • Magnesium sulphate admin for neuroprotection

Fetal Fibronectin Test

• Fetal fibronectin is a fibronectin protein produced by fetal cells between chorion & decidua

• Is adhesive that binds fetal sac to uterine lining

• Vaginal swab down when preterm labour is suspected & done routinely between 22-34 weeks of gestation

• Positive test = glue has been disturbed & risk of premature birth within seven days

  • Birth isn’t certain if positive

  • Is only predicator of birth & assist with decisions to transport/medical therapy

Tocolytics for Preterm labour

• Medications affects uterine muscle conductivity to slow/stop preterm labour contractions

• Not given to women as risk or is having imminent preterm birth

• Nifedipine: calcium channel blocker; used in women less than 34 weeks gestation. Effects cardiac, vascular & nonvascular SM in addition to uterus. Requires close nursing observation & assessment

• Indomethacin: NSAID; inhibits production of prostaglandins which influence onset & maintained of labour. Used for pregnancies less than 32 weeks gestation. Can be associated w/ effects on fetus after 32 weeks if used longer than 48 hours (premature closure of ducuts arteriosus & oligohydramnios)

• Risk benefit should be used to determine use of meds

maternal mortality ratio (MMR)

• ratio of pregnancy related deaths per 100,000 lie births

• Maternal death is defined as death of woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration & site of pregnancy from any cause r/t to or aggravated by the pregnancy or its management but not from accidental or incidental causes

• Main indicator of country’s health

severe maternal mobidity

• conditions that are along side the continuum to maternal death, including life-threatening & disabling disease, organ dysfunction & or receipt of invasive therapy during pregnancy or within 42 days after birth

Canadian & USA Maternal Morbidity & Mortality Rates

• are on the rise

• Canada is underreporting their MRR

• Based on WHO Canada has 3rd highest MRR

Post-partum care canada

• Average length of hospital stay is 2 days after vaginal birth & 3.4 days after c-section

• Postpartum care is component of maternity care that is most negatively perceived by mothers

  • Concerns often r/t need for inpatient care to be more person centered & flexible

Strategies to Improve Maternal Morbidity & Mortality Rates during Post-partum period

• Improve standard postpartum discharge education

  • pain in chest

  • obstructed breathing or SOB

  • Seizures

  • Thoughts of hurting yourself or infant

  • Bleeding

  • Incisions that aren’t healing

  • Red or swollen leg that is painful or warm to touch

  • Temp >100.4

  • Headache that won’t go away or w/ vision changes

• Enhance timing of postpartum care services

  • woman normally don’t see a doctor for 6 weeks postpartum (vaginal) or 4 weeks postpartum (c-section)

  • woman with high-risk concerns of pregnancies should be followed up earlier

  • post-partum services end 42 days post birth, but not all woman are full recovered

• Improve quality of postpartum care

  • standardization of comprehensive assessment of physical, social & psychological well-being as well as reassessment of nonpregnancy or pre-pregnancy related health

  • Standardization of patient education

    • Women report wanting education of birth control, physical activity, sexuality, nutrition, depression, infant feeding, water retention & future complications during postpartum appointments

• Enhance social & Mental health support

• Reducing postoperative complications by decreasing rates of c-sections

• Expand public health policies, advocacy & education outside the obstetrical realm

Indigenous Woman Disparities in Perinatal Care

• 2x higher risk of maternal mortality than general pop. & have higher rates of adverse outcomes

• Trans-generational effects of trauma of colonization contributes to many of inequities in health and well-being

• Negative experiences involved woman experiencing racism, cultural insensitivity & limited control over their care

• Maternal & infant health outcomes are affected by socio-cultural & socio-economic status of Indigenous people

  • smoking & alcohol consumption during pregnancy

  • Chronic illness such as diabetes

  • Presence of hazardous environmental contaminants

Attachment theory

• infant attachment is relationship between child & caregiver & is grounded in safety, security & protection

  • Child uses caregiver as a secure base to explore & as a source of comfort & safety

• Maternal-infant relationships

  • Bonding: the initial emotional connection between birth parent & newborn; starts postnatally

  • Maternal-fetal attachment: relationship that develops during initial years of life; starts in prenatal period

Maternal mental health in Canada Statistics

• 23% of mother who recently gave birth in Canada reported feelings consistent with either post-partum depression or an anxiety disorder

• 31% in Nova Scotia

Neonatal Death vs Fetal Death

• neonatal death: newborn - 28 days of life

• fetal death: >/= 20 weeks gestation

• miscarriage: < 20 weeks gestation