Introduction to Perinatal Nursing & Maternal Physiological Adaptations and Assessment

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 (< 10^th %): cigarette smoking

      • SGA: small for gestational age 

    • LGA (> 90^th %): 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 1^st 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