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Focus of Perinatal Nursing
Specialty in Canada
Focus: women, their infants and families during the childbearing cycle.
Focus: physical, psychologic, and social needs of women throughout their life spans.
Values of Perinatal Nursing
Caring Relationships
Confidentiality
Health and Well-Being
Justice (human rights and fairness)
Informed Decision-Making
Accountability
Dignity
Safe, Supportive Practice environment
Collaborative Care
Collaborative Care
Woman and FCC Maternity & Newborn Care
Cultural Diversity & Practices in Childbearing families
Interdisciplinary
Interprofessional Education (IPE)
Client care will improve when health professionals work together.
Teamwork and communication are key aspects of IPE
Situation, background, assessment, recommendation (SBAR)
The interprofessional collaborative practice competencies include:
Values/ethics for interprofessional practice
Roles/responsibilities
Interprofessional communication
Teams and teamwork
Perinatal Current Issues
Promoting health and normal birth
Place of birth and “high-tech” care
Midwifery
Baby Friendly Initiative
Patient safety and risk management
Community-based care
Elective C-Sections
Health literacy
Global perspective
Baby Friendly Initiative
outpatient programs
if you see, there will be some indications as to why it’s needed
Irish Twins
born within same calendar year or 9 months of each other
Mom didn't wait 6 weeks (couldn't)
Allocation of Resources
perinatal nursing 1:1, care we give to women in labor 1:1
typical labor, not extensive interventions
very important that if something goes south there's enough resources / skilled people to deal w/ it (decided it matters)
can be diverted to soonest available bef (may be diff hospital)
dyad
Infant and Mother
can go up to 5 dyads (10 pts)
Elective C-Section
runs at a rate of 32%
Crept up b/c used to think that once you had a c-section, all following births needed to be c-sections
Stagnated b/c moms have the choice - more moms choose subsequent c-sections than don’t
Maternal Mortality Rate
Mom Death
6.1 in 100,000 live births
Infant Mortality Rates
Inadequate nutrition; no ability to maintain nutrition to support growth of fetus
safety, partner ability to take care of her, housing, water, family, support, access and know about prenatal education
manage, alter birth plan
Prematurity: earlier a baby is born the increased infant mortality rate
Maternal Morbidity Rate
Complication
15.5 per 1,000 deliveries
Fertility/Birth Rate
but multifactorial (not d/t waiting)
around 35 is when female fertility starts to drop off
Multiple Birth Rate
more than one baby on the inside
fertility tx + age tx
female body as it ages tends to throw more eggs out
2.8 (2001) – 3.2 % (2010)
Preterm Birth/Birth Rate
2.2% (2010)
Gestational age - how many wks of fetal development
SGA (< 10th %): cigarette smoking
SGA: small for gestational age
LGA (> 90th %): diabetes [shoulder dystocia, nerve injuries, PPH
LGA: large for gestational age
Obesity; 45% self-report (Hypertension, congenital abnormalities, miscarriage, fetal death)
Obesity impacts perinatal care (CV function and nutrition)
C-Section Rates
increased 17.6% in 1995 to 28% in 2011.
Ethical Issues
Reproductive technology
Allocation of resources
Older-age pregnancies
Induced ovulation and in vitro fertilization
HIV- positive women seeking assisted reproduction
Multifetal pregnancy reduction
Intrauterine fetal surgery
Treatment of very low-birth-weight infants (< 1000 gms/2 lbs 2 oz)
Indigenous Health
LGBTQIA2S+
What is Postpartum Care?
Referred to as puerperium or “fourth trimester of pregnancy”
lasts 6 weeks (varies among women)
Postpartum period
interval between birth and return of reproductive organs to their nonpregnant state
When do the organs return to the nonpregnant state
Usually 1 month to 6 weeks
Last visits w/ midwife and GP
mom allowed to do at 6 weeks
6 weeks is when cervix closes again, barrier against bacterial border, vascularity reduced, want it to relax and close
Post-Partum Uterus
Fundal height and lochia are indicators of the progression of uterine involution.
Includes: Involution Process and Sub involution process
Contractions
Retained placental fragments
Pieces of the placenta that did not get delivered
body keeps pumping blood towards that could lead to hemorrhage
that fragment is dying tissue, so can easily become infected
can stop contraction of uterus; can still send pregnancy signals to body
Involution Process (Uterus)
return of uterus to true pelvis after birth
Progresses rapidly
Fundus descends 1 to 2 cm every 24 hours
2 weeks after childbirth uterus lies in true pelvis
Sub Involution Process (Uterus)
failure of uterus to return to non-pregnant state
Common causes are retained placental fragments and infection.
Contractions (Uterus)
Hemostasis achieved by compression of blood vessels as uterine muscle contracts (as opposed to platelet aggregation or clot formation).
Hormone oxytocin, released from pituitary gland, strengthens and coordinates uterine contractions.
After pains
Placental site (vascular constriction & thrombosis reduce the placental site)
True Pelvis
bony part down
False Pelvis
structural part above
we want involution not sub involution
Lochia
Post birth uterine discharge
Lochia rubra
Bright red flow
Blood and decidual debris (mucosal lining of uterus)
Duration of 3 to 4 days
Lochia serosa
Old blood, serum, leukocytes, and debris
Median duration of 22 to 27 days
Lochia alba
Leukocytes, decidua, epithelial cells, mucus, serum, and bacteria
Continues 4 to 8 weeks after birth
Cervix
Soft immediately after birth
been thinned out and stretched out and the relaxes
Within 2 to 3 postpartum days, cervix is 2 to 3 cm, and by 1 week, it is about 1 cm.
os = single hole w/ two openings (inner and outer)
Ectocervix appears bruised and has small lacerations—optimal conditions to develop infections
Ectocervix
portion of the cervix that protrudes into vagina
moist, warm, area, during pregnancy more at risk for infection
Vagina and Perineum
Vagina gradually decreases in size and regains tone (never completely returns to pre-pregnancy state)
Estrogen deprivation
Thickening of vaginal mucosa occurs with return of ovarian function.
Dryness and coital discomfort (dyspareunia) may persist until return of ovarian function
Episiotomies heal within about 2 weeks
Hemorrhoids (anal varicosities) are common and decrease within 6 weeks of childbirth
Pelvic muscular support
Estrogen deprivation
responsible for thinness of vaginal mucosa and absence of rugae (muscular folds on internal wall of vagina)
lays at low level (no spikes); stays low for some time afterwards
progesterone stays up during pregnancy
low estrogen = vaginal dryness - uncomfortable and hurts
breastfeeding exacerbates it
Pelvic Muscular Support
Supportive tissues of pelvic floor torn or stretched during childbirth
Requires up to 6 months to regain tone
Kegel exercises encourage healing
Breasts: Breastfeeding Mothers
The return of ovulation and menses is determined in part by whether or not the woman is lactating (breastfeeding).
Colostrum – early milk (yellowish fluid can be expressed from nipples)
Tenderness may persist for 48 hours after start of lactation.
Transitions to milk in 72 to 96 hours – Lactogenesis
Engorgement comfort measures for lactating moms
Breasts: Non-breastfeeding Mothers
The return of ovulation and menses is determined in part by whether or not the woman is lactating (breastfeeding).
Engorgement resolves in 24 – 36 hours after milk comes in
Breast binder /tight bra, ice packs, fresh cabbage leaves, or mild analgesics may be used to relieve discomfort.
Lactation ceases within a few days to 1 week
Cardiovascular System: Blood Volume
Average blood loss range for vaginal birth: up to 500 mL
Average blood loss range for a Caesarean birth: 500 mL to 1000 mL
Blood volume decreases within a few days as a result of diuresis
Cardiovascular System: Cardiac output
Remains increased for 48 hours after birth
Vital signs – HR, BP return to normal after 2-3 days. RR returns to normal.
Cardiovascular System: Blood components
Hematocrit and hemoglobin – moderate drop for 2-4 days, then normal by 8 weeks PP
White blood cell count – normal by 10 – 12 days
Coagulation factors – elevated with risk for thromboembolism
* C/S - encourage movement
Cardiovascular System: Varicosities
Total or nearly total regression of varicosities is expected after childbirth
Respiratory System
Immediate decrease in intra-abdominal pressure at birth causing an increase in chest wall compliance
decreased pressure on diaphragm
Reduced pulmonary blood flow
Rib cage elasticity can take months to return to a
pre-pregnancy state.
Loss of placenta = decreased progesterone = PaCO2 levels to rise
Basal metabolic rate (BMR) returns to pre-pregnancy levels within 1 to 2 weeks after birth.
After pains
all contractions after delivery
may be covered with tylenol/advil
more babies she’s had = more impactful
Endocrine System: Placental Hormones
Expulsion of placenta = decreased estrogen & progesterone levels
Decreases in human chorionic somatomammotropin (hCS) also known as human placental lactogen) estrogens, cortisol, and placental enzyme insulinase reverse effects of pregnancy including reversal of the diabetogenic effects of pregnancy leading to sig. lower blood sugar levels.
Mothers with Type I Diabetes often require much less insulin for a few days post birth
Mothers with Gestational Diabetes often have resolution immediately or within days after birth
hCG (Human Chorionic gonadotropin) disappears quickly from maternal circulation (detectible for 3-4 weeks post birth)
Endocrine System: Pituitary hormones
Prolactin Levels are highest levels during 1st month in women who breastfeed & remain elevated in women who breastfeed
Influenced by frequency of breastfeeding, duration of each feed and supplementary feeds, strength of infant suck
Endocrine System: ovarian function
Ovulation in 27 days after birth for non-lactating women
Ovulation in 70 to 75 days for lactating women
BF women - return of ovulation depends on breastfeeding patterns
May ovulate before first menstrual cycle
pressure cauterization
compression of BV in uterine muscles is allowing clot formation
if mom doesn’t have contractions, then no pressure to end the blood flow
Urinary System: Urine components
Renal glycosuria disappears by 1 week postpartum
Lactosuria may occur in lactating women
Blood urea Nitrogen (BUN) increases with autolysis of the involuting uterus
Pregnancy associated proteinuria resolves by 6 weeks post birth
Ketonuria persists in some women with uncomplicated birth or after a prolonged labour with dehydration
Urinary System: Fluid Loss
Diuresis of extracellular fluid
Profuse diaphoresis often occurs at night for the first 2 to 3 days
Urinary System: Urethra and Bladder
Excessive bleeding can occur because of displacement of the uterus if the bladder is distended
Stress incontinence
Gastrointestinal System: Appetite
Most new mothers are very hungry after recovery from analgesia, anaesthesia, and fatigue.
Gastrointestinal System: Bowel Evacuation
Spontaneous bowel movements may not occur for 2 to 3 days after childbirth:
Decreased muscle tone in intestines during labour and immediate puerperium, pre-labour diarrhea, lack of food, dehydration.
Discomfort due to perineal tenderness, episiotomy, lacerations or hemorrhoids (ie. mothers may resist the urge).
Forceps/Vacuum/Anal sphincter lacerations - increased risk of postpartum incontinence (flatus). Should resolve by 6 months.
C/S – abdominal pain from buildup of flatus. Encourage mom to move to enhance movement of intestinal system.
Integumentary System
Melasma (Chloasma/mask of pregnancy) disappears in the postpartum period.
Persists in about 30% of women.
Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth.
Some women will have permanent darker pigmentation of those areas.
Striae gravidarum - Stretch marks on breasts, abdomen, and thighs may fade but not disappear.
Hair Loss during 3 month PP
Fingernails return to prepregnancy consistency and strength
Musculoskeletal System
Take 6 weeks for abdominal wall to return to almost prepregnancy state (depends on prior tone, exercise)
Diastasis recti abdominis = the abdominal wall muscles separate
Joints are stabilized by 6 to 8 weeks after birth
Ongoing hypermobility of joints
Change in mother’s center of gravity
A new mother may notice a permanent increase in
shoe size
Neurological System
Changes with reversal of maternal adaptations to pregnancy and from personal labour & birth story
Headache common in first PP week due to fluid balance
Requires careful assessment
Postpartum headaches
may be due to:
postpartum-onset pre-eclampsia
stress
leakage of cerebrospinal fluid into the extradural space during placement of the needle for administration of epidural or spinal anaesthesia.
Immune System
Immune system, mildly suppressed during pregnancy
Gradually returns to the pre-pregnancy state
No exact timeline
This rebound of immune system can trigger “flare-ups” of autoimmune conditions (e.g., multiple sclerosis)
Which vital sign increase is a sign of puerperal sepsis?
An increased maternal temperature to 38 degrees or higher after the first 24 hours postpartum (or recurrent or persistent over the subsequent two days) may be a sign of puerperal sepsis
Hand Expression for breastfeeding
A: One hand is placed on breast with
thumb above and fingers below.
Press back toward chest.
B: Gently compress the breast while rolling
thumb and fingers forward. Maintain steady,
light pressure.
C: Relax. Rotate hand to all sections of breast.
Signs of Possible Postpartum Hemorrhage
V/s are out of range
U=Uterus is boggy (not firm)
P= Pain
Pain could indicate retained tissue
No pain could indicate lack of contracting in the uterus
L= Lochia
Is a steady trickle or gush with uterine massage or ambulation
Saturated pad < 1 hour
Action for Postpartum Hemorrhage
Action=Report Now
Retake VS and watch sedation
Massage
Observe flow during fundal massage
Check under buttocks for pooling
Weigh pads or clots
Compare against previous pain assessments
What Impacts the Assessment?
Baseline Vitals
GTPAL
Birth HX
Blood Group and RH factor
Hypertension
Gestational Diabetes
Communicable Diseases (HIV, STI)
RH Incompatibility (mother RH neg/infant RH pos)
RH factor
Fetal RBCs enter into maternal circulation at time of birth. The mothers natural defense mechanism responds to alien cells by producing anti-RH antibodies.
Normal: there is not effect during the first pregnancy with an RH + fetus as initial sensitization rarely occurs before the onset of labour.
Abnormal: with increased risk of fetal blood being transferred to maternal circulation during placental separation= maternal antibody production is stimulated.
During a subsequent pregnancy with a RH + fetus, maternal antibodies enter fetal circulation where they attack and destroy fetal erythrocytes
Gravida
woman who is pregnant
Gravidity
pregnancy
Multigravida
woman who has had two or more pregnancies
VBAC (vaginal birth after cesarean)
criteria must be met
must be in hospital in case of emergency
TOL (Trial of labour)
Trial of labour for a vaginal birth after Caesarean (VBAC)
Multipara
woman who has completed two or more pregnancies to 20+ weeks gestation
Nulligravida
woman who has never been pregnant
Nullipara
woman who has not completed a pregnancy with beyond 20 weeks gestation
Preterm
pregnancy between 20-0 and 36-6
Primigravida
woman who is pregnant for the first time
Primipara
woman who has completed one pregnancy with fetus or fetuses who have reached 20 weeks of gestation
Term
pregnancy from 37-0 to 41-6
Viability
capacity to live outside the uterus (22 – 25 weeks gestation)
People involved in perinatal care
Doula
GP
Perinatal Nurse
OBGYN
Partner
Anaesthesiologist
Doula package
typical package: under $1000 = 3ish visits, understand interests in birth plans, don’t need liability (can’t prescribe or admin); talking about what kind of relationship you want with them and may meet with you after according to package
Doula
“birth companion”
not registered - education does not exist (non-medical professional)
side business, paid privately, advertise what they are offering
biggest thing: with you for the entire labor
some advocate for you, pushing back against GP/nurse, firm advocate; some can't be quite challenging (counselling pt away from something)
can be one of the team, blessed to have in the room with you
Midwife(Registered Midwife in Canada)
4 year degree program + practicums
follow ups, at the birth
paid by the government (don’t pay for it) - paid for gamete of care (compared to GP who is paid per visit)
not structurally paid the same, can’t have as many patients as a GP
Perinatal nurse
not every country has perinatal nurses
have specialized education
follow up care / outpatient / home visits (physical or SDOH reasons)
recognizes risks and care related to that; work in areas of fertility; postpartum follow ups; antenatal clinics
can be a postpartum only nurse (NRP, breastfeeding course)
community nurses
public health nurses
Oxytocin Induction
needs or needs supplemental to have contractions during labor
IV delivery of this naturally occurring hormone; contractions may be weak/irregular
oxytocin = “love hormone” produced during female orgasm
different level and different response
Ruage
stretched out during birth, tear = scar tissue, elasticizing the scar tissue
feels and same sensory
looks different
coital discomfort
pain and discomfort from something going into the vagina
episiotomy
snip of perineum for baby to come out - local anaesthetic (won’t feel it until later; tightness from the stitches)
Tears
1st and 2nd degree may not be stitched
2nd more likely to be stitched
3rd and 4th definitely stitched
Hemorrhoids
more common in pregnancy period
sometimes and issue during the birthing period
varicose vein in the inside of anus; cant go on the outside
constipation and hormonal changes common in pregnancy - causing them to develop