2546 Lecture 1

Scope of Perinatal Nursing in Canada

• care for child-bearing pt, children, families in many settings

• hospital, home, community, ambulatory

• work collaboratively with other members of interprofessional healthcare team (physicians, midwives, social worker)

• work collaboratively with families through preconception, pregnancy, birth, post-partum, transition

Family-centered care

• respect and culture safety, involvement and participation, information sharing and collaboration, active involvement in decision making

• objective = healthy person giving birth to a healthy baby

CAPWHN Perinatal Nursing Standards in Canada (7)

1. caring

2. health/well-being

3. justice

4. informed decision making

5. dignity

6. confidentiality

7. accountability

Current Issues

• indigenous women (disrupted traditional birthing experience, leaving communities, being seperated from baby)

• unhoused and pregnancy (more unlikely to seek prenatal care, nutritional deficiency, increased mental health risks, etc)

• LGBTQ2 (lack of inclusive language, lack of knowledge of community)

• Global Concerns (human trafficking, birth tourisms (no prenatal records, laguage barrier))

• SDOH (biggest impact on outcomes)

GTPAL

• Gravida - # of all pregnancies (including current)

• Term births - 37 weeks

• pre-term birth - 20-37 weeks

• abortions/miscarriages - before 20 weeks

• living children

twins = 1 pregancy = G1L2

preconception factors (3)

1. health promotion

2. risk assessment

3. interventions

social determinants of health (SDOH)

• income and social status

• education and literacy

• social environment

• physical environment

• healthy behaviours

• biology and genetic endowment

• access to health services

• culture

maternal nutrition

• adequate dietary intake

• food supply

  • quality

  • availability

  • accessibility

  • cultural influence

• nutritional assessment

  • appropriate BMI

  • adequacy and quality of foods/eating habits

  • intervention based on dietary requirements

prevention of NTDs

• neural tube begins to close in 1st month gestation

• ALL pt of reproductive years should be counselled about a folate rich diet

  • supplements needed for optimal prevention

Low risk NTDs

• no risk factors

• 0.4mg in daily multivitamin 2-3 months pre-pregnancy, throughout pregnancy, during breast feeding

Moderate risk NTDs

• risk factors such as diabetes, epilepsy, obesity, family hx

• 1.0mg 3 months before pregnancy, continue to 1st trimester, then reduce to 0,4mg

High risk NTDs

• risk factors such as bio parent or previous pregnancy with NTD

• 4mg for 3 months before pregnancy and throughout 1st trimester, then reduce to 0.4-1.0mg daily

menstrual cycle

• endometrial

  • menstrual

  • proliferative

  • secretory

  • ischemic

• hypothalamic-pituitary

• ovarian

endometrial

• layers tissue line uterus

• functional layer that sheds during monthly cycles

menstrual - endometrial

• day 1-5

• shedding of functional layer of endometrium b/c hormone levels low

proliferative - endometrial

• day 5-14

• endometrium regrows, thickens, vascularized, rising estrogen stimulates regrowth of uterine line

secretory - endometrial

• day 14-28

• high levels of progesterone prepares endometrium for implantation

  • rich in blood supply, nourish fertilized embryo

ischemic - endometrial

• if pregnancy does not occur, corpus luteum degenerates = drop in progesterone levels = vasoconstriction = breakdown of endometrial lining

hypothalamic-pituitary

• end of menstrual cycle = estrogen/progesterone drop = FBL trigger release of follicle

• GnRH release FSH and LH

  • FSH = growth of ovarian follicles

  • LH = trigger ovulation and hormone production

ovarian

• hormonal changes trigger ovaries to release egg (ovulation)

  • 1-30 follicle start to develop, dominant one picked by lutinal

• follicular phase = FSH stimulates follicle growth, creates dominant follicle, lining thickens to prepare for pregnancy

• ovulation = day 14 = surge in LH hormone = mature follicle rupture and release from ovary

• luteal phase = rupture follicle transforms into corpus luteum (produces progesterone

  • if fertilization does not occur, corpus luteum breaks down, hormone levels drop, uterine lining sheds = menstruation (start of new cycle)

most likely to get pregnant…

• during day 6 of fertilization window (5 days with day 6 being ovulation) and 5 days before (with day 6 being egg drop)

  • egg implantation

  • trophoblast cells latch onto lining of uterus = some spotting

confirmation of pregnancy

• human chorionic gonadotropin (beta hCG)

• detected in urine and serum (blood)

  • 8-10 days post implantation, only test when period missed

  • 1st morning void has higher levels

signs of pregnancy

• presumptive

• probable

• positive

presumptive - signs of pregnancy

• subjective changes reported by pt

  • fatigue, breast changes, amenorrhea (absent period)

probable - signs of pregnancy

• objective changes seen by an examiner

  • hegar sign = softening of cervix

  • ballottement = increased body fluid in cavity

  • pregnancy tests

positive - signs of pregnancy

• objective signs seen by examiner attributed only ro presence of fetus

• observed fetus on ultrasound

estimated date of birth (EDB)

• last menstrual period (LMP)

• basal body temperature

• date of intercourse

• 1st trimester ultrasound

• naegele’s rule

naegele’s rule

• add 7 days and 9 months to LMP

• ex) LMP was Sept 10, 2021

  • EDB = June 17th, 2022

uterus

• endometrium layer - inner lining

• myometrium - muscle layer

• perimetrium - outer serous layer

• responsible for retention, reception, implantation, nutrition of pregnancy

cervix

• fibrous connective/elastic tissue - must be fully dilated for birth

• internal os - to uterus

• external os - to vagina

vagina

• birth canal - vulva to cervix

• rugae - expands during childbirth

pelvis

• true pelvis = inferior part of the pelvic cavity, lying below pelvic brim (inlet) and above pelvic outlet

• female = broader, wider, shallower

placental development

• syncytiotrophoblasts = anchor wall of uterus

• blastomere = embryo

• tropoblast = placenta

• Curtidons = separate segments of placenta

• anchors maternal side to fetal side to get maternal blood supply

placental functions

• endocrine glands

• metabolic

  • respiration

  • nutrition

  • excretion

  • storage

endocrine glands - placental functions

• produces hormone for pregnancy

  • trophoblast produced beta-hCG = function of corpus luteum = production of progesterone/estrogen = pregnancy development until end of 1st trimester when placenta takes over

metabolic - placental functions

• respiration = fetal lungs do no exchange gas, O2 diffuses across placenta

• nutrition = glucose metabolism for growing fetus (active transport)

• excretion

• storage = salts, electrolytes, cards, etc for fetus

umbilical chord

• embryonic disc = where baby develops

  • connected yolk sac = nutrients before placenta takes over

• trophoblast cells connected by connecting stalk

  • 5th week, embryo curves to ventral side = umbilical chord

• 2 arteries, 1 vein

  • arteries carry deoxygenated blood/waste from fetus to placenta

  • vein carries oxygen rich blood from placenta to fetus

amniotic fluid and sac

• week 11 = fetus urinates = increased in volume through gestation

• term - 700-1,00mL (too much/little dangerous)

• baby in amniotic sac in uterus

• maintain constant temp

• cushion for fetus from trauma

• infection barrier

• fetal lung development

• symmetrical movements of limbs

maternal adaption

• accepting the pregnancy

• identifying with the mother role

• reordering personal relationships

• establishing a relationship with the fetus

  • phase 1 = I am pregnant (accepting biological fact)

  • phase 2 = I am going to have a baby

  • phase 3 = I am going to be a mother

• preparing for birth

tasks need to happen for development, no specific time frame

paternal adaption

• accepting the pregnancy

  • couvade syndrome - men experiencing pregnancy symptoms

  • announcement phase (1) = few hours-weeks

    • accepting biological fact of pregnancy

  • moratorim phase (2)

    • adjusts/accepts pregnancy

  • focusing phases

    • last trimester, active involvement in pregnancy

• identifying with father role

• reordering relationships

• establishing a relationship with the fetus

• preparing for birth

adaptions for the non-pregnant parter

• same fears, questions, concerns

• better inclusion felt with engagement in process

sibling adaption

• 1 year old = unaware

• 2 year old = mother’s appearance change, unaware

• 3-4 year old = told own birth story, listen to heartbeat/fetal movements, worries about baby wears/eats

• school-aged = clinical interest, views self as mother/father

• early/middle adolescents = pre-occupied with own sexual identity

• late adolescents = comforting to parents, more like adults

Perinatal Care Choices

• physicians

  • family physicians (rural do all)

  • obstetrics

  • maternal fetal medicine (extra training)

• midwife (home/hospital visits)

choose physician or midwife for OHIP

• doula (non-clincal support in pregnancy)