Foundations of Childbearing

Changes through the 20th century

• Increase in knowledge

• Technology Advances

• Government funding

• Oversight & regulations

• Cost containment efforts

• Consumers as decision makers

• Increased complexity of care

Safety and Quality

• Maternal & infant mortality

• Rural vs. urban areas

• Racial and social disparities

  • Social determinants

  • Implicit bias

  • Racism

Programs to Improve Safety and Quality

• The Joint Commission

• Interprofessional Collaboration and education

• Alliance for Innovation on Maternal Health

• Women’s Health and Perinatal Nursing Care Quality Measures

The Joint Commission

Accredits healthcare organizations and sets safety and quality standards, including in maternal and newborn care.

Interprofessional Collaboration and Education

Brings different healthcare professionals together to learn and work as a team for better patient outcomes

Alliance for Innovation on Maternal Health

Provides evidence-based safety bundles to help reduce maternal deaths and complications

Womens health and Perinatal Nursing Care Quality Measures

Tracks standardized indicators to assess and improve maternal and newborn care qualit

Choices of Childbirth: Healthcare provider

• Physician, Physician Assistant

• Nurse Practitioner, Certified Nurse Midwife, Certified Midwife, CPM

Choices of Childbirth: Birth Setting

• Hospitals

• Birth Centers

• Home Births

Choices of Childbirth: Support Person

• Doulas: Paid help that supports mothers through labor and delivery

• Siblings, Mom, Dad etc.

Choices of Childbirth Education

• Women have choices- role of nurse is to help with education

• Bradley Method

  • Significant other helps to provide care

• Biggest piece of nursing

Factors Affecting Pernatal and Womens Health Care

• Healthy People 2030

• Cost Containment

• Community based perinatal and women’s health nursing

• Advances in technology

Complementary Alternative Medicine

• Safety issues

  • Self-referrals

  • Delay seeking care

  • Harmful therapies

  • Less strict regulations

Standards of Practice

• Statements of responsibility or duty

• Practice guidelines established by an authority such as the government, State Board of Nursing, accrediting agency, or professional organization

• Legal Standards

• Policies and procedures and protocols based on evidence based practice

• Frequent updates and periodic reviews

Essential Skills for Professional Nursing

• Critical Thinking

• Clinical Judgment

• The Nursing Process

  • Assessment

  • Analysis

  • Planning

    • Prioritizing

    • Goals/Objectives

  • Interventions

  • Evaluations

• Individualized Plan of Care

Family Structure

• Most common

  • Nuclear or conjugal

• Other structures

  • Extended, Single Parent, Adolescent mothers, Blended

  • Communal, Foster/Adoptive, Same-gender parents

Characteristics of a functional, health family

• Communicate openly

• Flexible in role assignments

• Agree on basic principles of parenting

• Resilience and adaptability

Factors that interfere with family functions

• Lack of financial resources

• Absence of adequate family support

• Infants with special needs

• Unhealthy habits

• Inability to make mature decisions on infant care

High risk family

• Lives below the poverty level

• Chronic food insecurity

• Single adolescent parent

• Unanticipated stressors

• Families with lifestyle problems

Cultural values

• Dominant Western cultural values

  • Democracy

  • Individualism

  • Cleanliness

  • Preoccupation

  • Reliance

  • Belief regarding optimal health

  • Admiration for self-sufficiency

  • Differing cultures and lack of understanding

Cultural Assessment

• Ethnic affiliation

• Childbearing viewpoints

• Prescribed practices

• Pain management

• Maternal restrictions/precautions

• Support

• Family

Cultural Negotiation

• Providing information

• Being sensitive to specific concerns

Social Issues: Socioeconomic Status

• Affluent, middle-class, working poor and unemployed

  • Nursing care plan: Socioeconomic problems

• New poor, poverty, homelessness

• Socioeconomic issues affect the patients' access to healthcare.

Social Issues: Disparity in healthcare

• Barriers to prenatal care

• Allocation of healthcare resources

• Care versus cure

• Solutions

• Government programs

  • Medicare, Medicaid, Children’s Health Insurance Program (CHIP)

  • Public Clinics

  • Temporary assistance to Needy Families (TANF)

  • Shelters and healthcare for the homeless

Social Issues: LGBTQ families

• Appropriate terms and preferences

• Health disparities

  • Suicide

  • Homelessness

  • Cancer

  • HIV and STDs

  • Obesity

  • Tobacco, alcohol. Drug use

• Issues prior to pregnancy 

• Pregnancy and Postpartum

• Implicit bias

• Mitigating implicit bias

Social Issues: Intimate Partner Violence

• Effects during pregnancy

• Factors that promote violence

• Characteristics of the abuser

• Cycle of violence

• Nurse’s role in prevention

• Human Trafficking

Ethics

involve determining the best course of action in a certain situation

Bioethics

is the application of ethics to healthcare 

Ethical Dilemma

• Situation in which no solution is completely satisfactory

• Must apply ethical theories and principles and determine the burdens and benefits in order to find solutions

Deontologic Model

• Determine what is right by applying ethical principles and moral rules

• Does not vary the solution according to individual situations

Utilitarian Model

Concerned more with the consequences of actions than the actions themselves

Human Rights Model

Belief that each person has human rights

Ethical principles

• Beneficence

• Nonmaleficence

• Respect for Autonomy

• Justice

• Other important ethical principles are derived from these four basic principles

Elective Pregnancy Termination

• Implication for nurses

  • Personal values

  • Professional obligations

    • Nurses have no obligation to support a position in which they disagree

    • Obligated to disclose this information

madated Contraception

• Used as a condition of probation

• Believed by some to be a reasonable approach

  • Women considered to be unsuitable parents

  • Reduce government expenses for dependent children

• Does not provide long-term solutions

• Interferes with constitutional rights

• Access to information

Fetal Injury

• State has interest in protecting children

• Some states prosecute the mother

  • Women can be charged with negligence, involuntary manslaughter, and child endangerment

• Some cases of forced cesarean births prevent fetal injury

• Fear of prosecution may lead mother to avoid prenatal care

• Maternal personal freedom versus fetal rights

Fetal Therapy

• Fetal therapy is becoming more common as techniques improve and knowledge increases

• Risks and benefits

  • Even when surgery is successful, fetus may not survive

  • The fetus may have other serious health problems or may be born severely preterm

  • There are maternal health considerations

• Parents need to understand the procedure, its success rates, and if alternative treatments are available

Infertility Treatment

• High costs may not be covered by insurance

• Invasive procedure

• Technique may benefit only a small percentage of infertile couples

• Ethical Issues

  • Unused embryos

  • Reduction surgery

• Postmenopausal pregnancy

Issues with Infertility: Surrogate Parenting

• Woman agrees to bear an infant for another woman

• Ethical issues

  • Surrogate mother wants to keep child

  • Role of surrogate mother after birth

  • Screening of parents and surrogates

  • Use of donor gametes or unused embryos

Issues with Infertility: Privacy Issues

• Misuse of information

• Privacy concerns

• Fear of medical insurance loss

• Quality of genetic counseling

• Refusal to release medical records

Issues with Infertility: Government Regulations

• The Health Insurance Portability and Accountability Act 

• US Department of Health and Human Services (HHS) regulations provide consumers with significant new power over their records

Issues with Infertility: Electronic Communications

• Electronic Health Records

  • Potential for Violation of privacy

  • Security measures

• Social Media

Nurse Practice Acts

• Determine the scope of practice of registered nurses (RNs) in that state

• Specify what nurse is expected to do when providing care

Standard of Care

• Set by professional associations

• Describe the level of care that can be expected from practitioners

Agency Policies

• Each healthcare agency sets specific policies, procedures, and protocols

• Nurses are often involved in writing and updating policies

• Policies are used as evidence in the event of a malpractice claim

Malpractice, Limiting loss

• Refusal of care

  • Patients have right to refuse care

  • Need to establish that the patient understands the treatment and consequences of refusal

• Documentation

  • Documentation is the best evidence that a standard of care has been maintained

  • Documentation must be specific and complete

• Competence

• Understanding information

• Documenting discharge care

• Documenting incidents

• The nurse as client advocate

  • Nurses are ethically and legally bound to act as the patient’s advocate

• Maintaining expertise

  • Nurses can reduce malpractice liability by maintaining expertise

  • States require proof of continuing

Cost Containment and Downsizing: Delegation to Unlicensed Assistive Personnel

• The UAP must be identified to the client as non-licensed

• Nurses remain legally responsible for client assessment

• Nurses must make the critical judgments necessary to ensure client safety

Cost Containment and Downsizing: Early Discharge

• Can reduce risk for hospital acquired infection and prompt ambulation

• Concerns about the new mother’s ability to care for herself and her baby so soon after birth

• Parents at home may not recognize development of serious maternal or neonatal infection or jaundice

Cost Containment and Downsizing: Methods for Dealing with Short Lengths of Stay

• Teaching begins at admission

• Self-care during pregnancy or in women’s health begins at first encounter

• Self-care and infant care discharge instructions should be explained to the woman and her support person

• Home visits, phone triage, and return to the birth facility

DNA

• Basic building block of genes

• Sequence of base pairs determines which amino acids will be assembled

Genes

• Direct production of a specific product is necessary for structure and function

• Not all genes function at the same time

• Genes that code for the same trait have alternate forms, or alleles

Chromosomes

• Genes are organized in 46 paired chromosomes

• Each chromosome is composed of varying numbers of genes

• Twenty-two chromosome pairs are autosomes

• The twenty-third pair makes up sex chromosomes

• Chromosomes are arranged into a karyotype

Alleles

Paired alleles may be identical (homozygous) or different (heterozygous)

Dominance

Describes the way a person’s genotype is translated in a phenotype or observable characteristics

Chromosome location

• Genes located on autosomes are dominant or recessive

• Genes located on the X chromosome are paired only in females

Patterns of Single Gene Inheritance: Autosomal Dominant Traits

• Produced by dominant gene on a non-sex chromosome

• Abnormal gene expression may vary in severity

• May carry a dominant gene but have no apparent expression

• Some having the abnormal gene will always have the disease

• New mutations can bring a trait into a family

Patterns of Single Gene Inheritance: Autosomal Recessive Traits

• Expressed if a person receives two copies of a recessive gene

• Abnormality is not expressed if compensated with normal gene

• Many recessive disorders are severe

Single Gene Abnormalities: X-Linked Traits

• Recessive is more common than dominant

• Males are usually the only ones who show effects of abnormal X-linked recessive trait

• Females can show full disorder in uncommon circumstances

• Can be mild (color blindness) or severe (hemophilia)

Chromosomal Abnormalities: Numerical Abnormalities—Trisomy

• Extra copy of one chromosome

• Chromosomes are normal but there are too many

Chromosomal Abnormalities: Numerical Abnormalities—Monosomy

• Each body cell has a missing chromosome

• Most often incompatible with life

Chromosomal Abnormalities: Numerical Abnormalities—Polyploidy

• Embryo has one or more extra sets of chromosomes

• Usually results in early spontaneous abortion

Chromosomal Abnormalities: Structural Abnormalities

• Part of chromosome may be missing or added

• DNA may be arranged

• Part of a chromosome is attached to another (translocation)

• May be clinically normal because total genetic material is normal

• Too much or too little chromosomal material

• X syndrome is the most common inherited form of male retardation

Multifactorial Disorders: Characteristics

• Interaction between genetic susceptibility and environment

• Present and detectable at birth

• Isolated defects

• May cause secondary defect

Multifactorial Disorders: Characteristics—Most Common

• Heart defects

• Neural tube defects

• Cleft lip/palate

• Pyloric stenosis

Multifactorial Disorders: Risk for Occurrence

• Number of affected closed relatives

• Severity of the disorder in family members

• Gender of affected person

• Geographic location

Environmental Influences: Teratogens

• Agents that cause birth defects

• Factors that make it difficult to establish teratogenic potential:

  • Retrospective study

  • Timing of exposure

  • Different susceptibility of organ systems

  • Uncontrolled fetal exposure

  • Placental transfer and individual variations

  • Maternal disorders (uncontrolled)

Environmental Influences: Types of Teratogens

• Maternal infectious agents

• Drugs

• Pollutants

• Ionizing radiation

• Maternal hyperthermia

• Maternal medical disorders

Environmental Influences: Preventing fetal exposure

• Ideally begins before conception

• Infections

• Drugs and other substances

• Ionizing radiation

• Maternal hyperthermia

Environmental Influences: Manipulating the fetal environment

• Appropriate medical therapy for diseases

• 400 mcg of folic acid daily before conception

Environmental Influences: Mechanical disruptions to fetal development

• Oligohydramnios

  • Clubfoot

  • Fetal lung development

• Fibrous amniotic bands

  • Fetal deformities

  • Intauterine limb amputation

Weight gain during pregnancy

• Weight gain recommendations based on the woman’s prepregnancy body mass index (BMI)

• Recommended weight gain is 11.5 to 16 kg (25 to 35lb) for women who begin pregnancy at normal BMI

• Recommended weight gain is 6.8 to 11.3 kg (15 to 25 lb) for women begin pregnancy overweight

• Recommended weight gain is 5 to 9.1 kg (11 to 20 lb) for women who begin pregnancy obese

Pattern of weight gain

• The general recommendations is an increment of about 0.5 to 2 kg (1.1 to 4.4 lb) during the first trimester

• Maternal and fetal distribution

Nutritional Requirements

• Measured in kilocalories 

• Carbohydrates

  • Simple or complex

• Fats

  • Provide energy and fat soluble vitamins

• Calories

  • Most pregnant women need 2200 to 2900 calories daily

• Nutrient density

  • The quantity and quality of various nutrients in each 100 calories of food

Nutritional Requirements: Protein

• Necessary for metabolism, tissue synthesis, and tissue repair 

• Daily protein RDA is 46g for nonpregnant females

• Daily recommended protein intake of 71g during pregnancy 

  • Expansion of blood volume

  • Growth of maternal and fetal tissues

Nutritional Requirements: Vitamins

• Fat-soluble

  • A,D,E, and K

  • Stored in liver

  • Excessive intake of these vitamins can be toxic

• Water-Soluble

  • B6,B12, and C; folic acid; thiamine; riboflavin and niacin 

  • Should be included in the daily diet

• Folic acid (also called folate)

  • Can decrease the occurrence of neural tube defects

Nutritional Requirements: Minerals

• Iron

  • Important in the formation of hemoglobin

  • During pregnancy approximately 1000 mg of absorbed iron above maternal iron stores are needed

• Calcium

  • Important for mineralization of fetal bones and teeth

  • Calcium absorption increases during pregnancy

• Sodium

  • Sodium needs are increased during pregnancy to provide for an expanded blood volume and the needs of the fetus

Nutritional Requirements: Nutritional Supplementation

• Food is the best source of nutrients

• Health care providers usually prescribe prenatal vitamin-mineral supplements

• Women with adequate diets may not need supplements except for iron and folic acid

• Assessment of each woman’s individualized needs determines whether supplementation is appropriate

Nutritional Requirements: Nutritional Supplementation (disadvantages)

• No standardization or regulation of the amounts of ingredients

• Excessive amounts of some vitamins and minerals may be toxic to the fetus

• Supplements are not food substitutes and do not contain all the nutrients needed during pregnancy

Nutritional Requirements: Water

• Water is important during pregnancy

• For the expanded blood volume

• As part of the increased maternal and fetal tissues

• Women should drink approximately 8 to 10 cups of fluids that are mostly water each day

Nutritional Requirements: Food Plan

• USDA MyPlate provides a guide for healthy eating

  • Whole grains

  • Vegetables and fruits

  • Dairy groups

  • Protein group

  • Other elements

• Food precautions

Nutrition After Birth

• Nutrition for lactating mother 

  • Energy

  • First 6 months of lactation, the estimated energy requirement is 330 additional calories

  • Second 6 months require 400 additional calories

• Protein

• Fats

• Vitamins and minerals

Nutrition After Birth (don’ts)

• Fluid

  • Alcohol

  • Caffeine

• Avoid fish with mercury levels

• Avoid herbal teas and remedies

• Avoid illicit drugs and tobacco

Nutrition for the nonlactating mother

• Can return to her prepregnancy diet

• The nurse should assess the mother’s understanding of the amount of food she needs from each food group

• Weight loss

Adolescent Pregnancy

• Incidence 

• Factors associated with teenage pregnancy

• Sex education

• Socioecomic implications

• Implications for client health

• Impact of teenage pregnancy on parenting

Delayed Pregnancy

• Maternal and fetal implications

• Advantages of delayed pregnancy

• Nursing considerations

  • Facilitating expression of emotions

  • Providing parenting information

Substance Abuse: Chemical Dependence

• Incidence

• Maternal and fetal effects

  • Tobacco

  • Alcohol

  • Marijuana

  • Cocaine

  • Bath Salts

  • Amphetamines/methamphetamine

  • Antidepressants

  • Opiates

• Diagnosis and management 

Birth of an Infant with Congenital Anomalies

• Factors influencing emotional responses of parents

  • Timing and manner of being told

  • Prior knowledge

  • Type of malformation

  • Irreparable congenital malformation

• Grief and mourning

• Nursing considerations

Perinatal Loss

• Early pregnancy loss

• Concurrent death and survival in multifetal pregnancy

• Perinatal palliative or hospice care services

• Previous pregnancy loss

Adoption

• Process 

• Therapeutic communication

• Teaching infant care to adoptive parents

• Surrogacy

Perinatal Psychological Complications

• Perinatal mood disorder and anxiety disorders

  • Postpartum depression

  • Postpartum psychosis

  • Postpartum anxiety disorders

Application of the Nursing Process: Perinatal Psychological Complications

• Assessment

• Identification of patient problems

• Planning: Expected outcomes

• Interventions

  • Providing anticipatory guidance

  • Demonstrating care

  • Helping the mother verbalize feelings

  • Enhance sensitivity to infant cues

  • Helping family members, discussing options and resources

• Evaluation