PROMOTING MATERNAL WELLNESS IN THE FAMILY

& COMMUNITY

Nursing 202

Elizabeth Hartman, RNC, MSN, CLC

Catherine Marin, MSN ©, RN, WHNP

Instructors,

Trends in Contemporary Childbirth

• Family-centered childbirth• Greater client choice: setting, caregiver, treatment/

management• Shorter hospital stays• Self-care movement: assume responsibility for one’s

own health• Culturally competent care• Community based or home care

Legal and Ethical Considerations

Legal Concerns:• Scope of practice• Standards of care• Protection of clients’

rights• Patient safety• Informed consent

• Emancipated minors• Refusal of treatment• Privacy/confidentiality

Ethical Concerns• Maternal-fetal conflict• Abortion• Fetal rights• Fetal/stem cell research• Assisted reproductive

technology

Critical Thinking The nurse manager is planning a presentation on ethical issues

in caring for the childbearing families. Which of the following should the nurse manager include as an example of maternal-fetal conflict?

A) A cesarean delivery of a breech fetus is court-ordered after the client refuses.

B) A client chooses an abortion after her fetus is diagnosed with a genetic anomaly.

C) A family of a child with leukemia requests cord blood banking at this birth.

D) A 39-year-old nulliparous client undergoes therapeutic insemination.

•

Statistical Measurements of Maternal and Child Health

Determine populations at risk, assess relationships between factors, establish databases for specific populations, evaluate success of care, etc.

• Birth rate: births per 1,000 pop.: 14• Infant mortality rate: death in first 12 months of life,

per 1,000 live births: 6.85• Neonatal death rate: death rate of infants in first 28 days

of life: 4.7%• Fetal death rate: death in utero at ≥ 20 wks gestation• Perinatal death rate: sum of fetal and neonatal rates• Maternal mortality rate: maternal deaths as direct result

of reproductive process, per 100,000 live births: 12

Family & Cultural CareChapter 2

• A group of people related by blood, marriage, adoption, or residence in same household (US Census Bureau)

• Family of orientation vs family of procreation

Trends Affecting the Family• Employment Trends

• Dual-earner households

• Changes in marriage & divorce rate

• Single parent families• Cohabitation

• Economic Trends• Delayed childbearing• Intentional childlessness

• Increased role of grandparents

Duvall’s Family Life Cycles(Age of Oldest Child Determines Stage, Table 2-1, pg 29)

• Stage 1: Beginning families

• Stage 2: Child-bearing families

• Stage 3: Families with preschool children

• Stage 4: Families with school-aged children

• Stage 5: Families with teenagers

• Stage 6: Families launching young adults

• Stage 7: Middle-aged parents

• Stage 8: Retirement and old age

Assessment of Families(Friedman Family Assessment Tool, Fig. 2-7, pg. 34)

• Family Type & Stage• Structure and function

• Family roles • Level of functioning

• Cultural associations• Religious affiliations• Support network• Communication patterns• Environmental considerations

Family Roles

• Nurturer• Provider• Decision-maker• Financial manager• Problem-solver• Health manager• Gatekeeper

Impact of Culture on Families, Childbearing & Childrearing

Culture: A view of the world and traditions that a specific social group uses and transmits to the next generation

Ethnicity: Cultural group into which a person was born

Cultural Values: Preferred ways of acting based on traditions

Transcultural nursing: Nursing care that is guided by cultural aspects and respects individual differences

Family PlanningChapter 5

Choosing a Method of Contraception• Decision may be made individually or as a couple• Should be made voluntarily with full knowledge of

advantages, disadvantages, effectiveness, side effects, contraindications & long-term effects

• May be influenced by culture, religion, personality, cost, effectiveness, availability, practicality (see Table 5-1, pg 90, Factors to Consider in Choosing Method)

• Consistency of use outweighs absolute reliability of the method

Fertility Awareness-Based Methods• Based on menstrual cycle

& identifying when woman ovulates

• Peak fertility is approximately 5 days before ovulation until 3 days after

• Natural Family Planning• Calendar Rhythm Method• Basal Body Temperature

Method• Cervical Mucus (Billings)

Method

• Advantages: safe, free, acceptable to religious beliefs

• Disadvantages: require extensive counseling to learn, interfere with spontaneity, require couple to maintain records for several cycles, difficult with irregular periods, may not be as reliable

Barrier Methods• Prevent transport of sperm

to ovum, immobilize sperm, or kill them. Often used with spermicide (a chemical barrier)

• Spermicide • Condoms• Diaphragm• Cervical Cap• Vaginal Sponge• Intrauterine Devices

• Advantages: safe, effective if used correctly, offer some protection against infection

• Disadvantages: require motivation & cooperation, may be used less consistently

• Good: if hormonal methods contraindicated, in early postpartum/lactation, have intercourse rarely/sporadically, need backup method

Hormonal Contraceptives

• Combination Estrogen-Progestin

• Action: inhibit ovulation, maintain atrophic endometrium & maintain thick cervical mucus

• Modes:• Combined oral

contraceptives (COC)• Patches• Vaginal Rings• Injections

• Advantages: safe, effective, quickly reversible, reduce PMS/pain with menses

• Disadvantages: Must remember to take, have many side effects (Table 5-2, pg. 99)

• Contraindicated: hx of thrombophlebitis/ thromboembolic disease, liver dx, CA, heavy smoking, gallbladder dx, HTN, DM, migraine with visual disturbance, hyperlipidemia

• ESTROGEN is the culprit

Progestin Only & Other Methods

• Long-Acting Progestin: Depo-Provera,

• IM every 3 months• Suppresses ovulation,

can be used by nursing moms

• May take 9 mos for fertility to return

• Should not be used more than 2 years--associated with CA loss from bones

• Postcoital Emergency Contraception--combo or progestin only

• Operative sterilization:• Vasectomy• Tubal ligation

• Nonoperative sterilization: Essure

• Abortion: surgical or medical (mifepristone)

Critical Thinking•

Instructions concerning the use of a diaphragm should include that it is an excellent method of contraception, provided that the woman:

A) Removes it promptly following intercourse and then douches.

B) Inserts it at least two hours prior to intercourse. C) Does not use any spermicidal creams or jellies with it. D) Leaves it in place for six hours following intercourse.

Sexually Transmitted Infection(Summary Table 6-1, pg 113)

• Prevention:• Education & counseling of at-risk people on safer sex

practices• ID infected, asymptomatic and symptomatic not-

likely-to-seek-treatment individuals• Effective diagnosis & treatment• Evaluation, treatment, counseling & education for

partners of people with STI• Preexposure vaccination (Gardasil)• Expedited partner therapy (infected person gets

prescription for partners, too)

Lower Genital Tract Infection (Vaginitis)Symptoms: ↑vaginal discharge, vulvar irritation/pruritis,

external dysuria, foul odor

• Bacterial Vaginosis (BV)• Thin, watery, white or gray, fishy smelling vaginal discharge• Predisposing Fx: frequent sex w/out condom, douching• Tx: Flagyl, Clindamycin• Associated with preterm labor and amniotic fluid infections

• Candidiasis (yeast)• Thick, white discharge, severe itching, dysuria/dyspareunia• Predisposing Fx: glycosuria, oral contraceptives, antibiotics,

pregnancy, DM, immunosuppressant drugs. (If recurrent, test for diabetes, HIV)

• Tx: local vaginal treatment with “azole” drugs or nystatin cream, tablets or suppositories

• Thrush in newborn

Trichomoniasis (trichomonas vaginalis)

• Often asymptomatic. Yellow-green, frothy, odorous

discharge & vulvar itching, dysuria, dyspareunia.• Tx: Flagyl until cured & avoid (avoid intercourse

alcohol)• Associated with premature rupture of membranes,

preterm birth, low birth weight and post-cesarean infection

• Usually, no fetal effects

Gonorrhea• Often asymptomatic in women. • Purulent, greenish-yellow vaginal discharge, dysuria,

urinary frequency. • Often occurs with chlamydia.• Treat both partners.• Tx: Antibiotics: cephalosporin plus azithromycin or

doxycycline for chlamydia co-infection. • Ophthalmia neonatorum which causes severe eye

infection and blindness in baby (prophylaxis with erythromycin ointment)

Chlamydia• Most common STI in U.S., especially adolescents/young adults• Often asymptomatic. Thin or mucopurulent discharge, friable

(bleeds easily) cervix, burning & frequency of urination & lower abdominal pain.

• Causes urethritis in men--often diagnosed in women after treatment of male partner.

• Tx: Doxycycline or azithromycin• Associated with premature rupture of membranes, preterm labor

and endometriosis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, ophthalmia neonatorum & chlamydial pneumonia in baby

• Prevention: annual screening of at-risk individuals & at first prenatal visit

Herpes Simplex Virus• Primary episode: herpes lesions, flulike symptoms,

genital pruritus or tingling. May recur at anytime.• Tx: No cure. Acyclovir, valcyclovir, famciclovir to

prevent recurrence & lessen symptoms (acyclovir in pgncy only for severe infection)

• Primary Infection during Pregnancy: severe congenital anomalies, miscarriage (SAB), preterm labor (PTL), intrauterine growth restriction (IUGR), infection

• If lesions present at time of labor, c-section to reduce chance of transmission to baby

Syphilis (treponema pallidum)

• Early stage (primary): chancre (painless ulcer), slight fever, weight loss, malaise.

• Secondary symptoms: condylamata lata (wartlike plaques), arthritis, enlargement of liver, spleen, lymph nodes, chronic sore throat

• Screening at first prenatal visit (VDRL or RPR)• Tx: penicillin. Before 16 wks prevents fetal

transmission.• Fetal effects: stillbirth, congenital anomalies, PTL &

IUGR

Human Papilloma Virus (genital warts)

• Over 120 types--most asymptomatic. Types 6 & 11--visible genital warts. Soft, greyish-pink, cauliflower-like lesions.

• Itching, bleed easily or be painful. Lesions may be in vagina or on cervix & visible only by colposcopy. Subclinical dx made by changes on Pap smear.

• Tx: podofilox solution (not used in pregnancy) or imiquimod cream for external lesions. Cryotherapy, trichloroacetic acid, laser ablation.

• Women with HPV need frequent Pap smears to monitor cervical cell changes--associated with cervical & anorectal cancers.

• Condoms to reduce transmission,• Gardasil vaccine (against 4 types which cause 90% of genital

warts & 70% of cervical cancer)

Teratogenic Maternal Infections

TORCH: cross placenta & cause fetal harm

• Toxoplasmosis: (raw meat, cat litter) associated with CNS damage, retinal deformities

• Other infections (syphilis, Hep B, HIV, etc)

• Rubella: deafness, mental/motor challenges, cardiac defects, cleft lip/palate

• Cytomegalovirus: severe neurological damage, eye damage, chronic liver dx

• Herpes Simplex, Primary Infection: severe congenital anomalies, SAB, PTL, IUGR, infection

Group B Streptococcal 20-30% of pregnant women are carriers Leading infectious cause of neonatal sepsis/mortality

in 1970s Infects neonates causing pneumonia, sepsis,

respiratory distress and meningitis Maternal screening 35-37 wks, Antibiotics (Ampicillin, clindamycin or

erythromycin) during labor or ROM

Other infections in pregnancy Table 20-8, pg 535

Hepatitis B or C

• Can infect neonates• Hep B vaccine for baby • Hepatitis B Immune Globulin (HBIG)

-if mom is positive (testing done at first prenatal visit)

Lower Urinary Tract Infection

• Cystitis/Urethritis• Risk factors: sex, use of diaphragm & spermicide,

delayed postcoital micturition, pregnancy & history of UTI

• Most common cause: e. coli • Dysuria, urgency & frequency, suprapubic or low

back pain, low-grade fever, hematuria• UA: ↑ leukocytes and bacteria• Tx: culture & sensitivity for causative pathogen &

appropriate antibiotic or other treatment.

Upper Urinary Tract Infection (Pyelonephritis)

• More common at end of pregnancy or early postpartum• During pregnancy: increased risk of preterm labor &

birth• Sudden onset: chills, high fever, costovertebral angle

tenderness or flank pain, nausea, vomiting, general malaise. Frequency, urgency & burning with urination.

• Urine culture: bacteremia, pyurea & presence of white blood cell casts.

• Tx: hospitalization, IV antibiotics, hydration, urinary analgesics (pyridium), pain management, antipyretics. Follow-up urine cultures.

Obesity in the USA• Epidemic• Up 74% in last 10 years• 300,000 deaths annually• 50% of American women• 16% of children 6-19• 1 in 20 American women obese + diabetic• Multifactoral etiology

Obesity in the USADefinitions -Obesity: BMI >29kg/m3 -Overweight: BMI 25-29

Medical Complications of Obesity • HTN • Hyperlipidemia • Type 2 DM • CAD • Cholecystits • Stroke • Gout • Osteoarthritis • Depression • Cancers: Endometrial, Colon, Breast • Kidney stones • Sleep Apnea • Incontinence

Surgical ComplicationsAnesthesia issues Wound DehiscenceDVT, PE HemorrhageInfection 10X more likely

Obesity in Pregnancy• BMI >29• Abdominal circumference > 40 inches – Tape measure at iliac crests• Morbid obesity >250#• Massive obesity >300#• Late Fetal Death BMI < 20 =1% BMI 20-25 =1.25% BMI 25-30 =1.75% BMI >30 =2.75%

Cnattingius, S, Bergstrom, R, Lipworth, L, Kramer, M. (1998). Prepregnancy weight and the risk of adverse pregnancy outcome. New England Journal of Medicine; 338:147.

Obesity:Fertility and Early Pregnancy

• Subfertility – If PCOS consider metformin• Spontaneous AB (RR 1.2) – High androgen levels – Insulin resistance• Recurrent miscarriage (RR 3.5)• Congenital malformations – NTDs: OR 3.5 – Cardiac: OR up to 6.5! – Omphalocele: OR 3.3• Suboptimal U/S visualization

Violence Against WomenChapter 9

• As many as 1 in 3 women will be abused• From 1998 to 2002, 1/3 of female murder victims were

killed by an intimate partner or ex-partner• Intimate partner violence results in nearly 2 million

injuries and 1300 deaths annually• Initiatives by JCAHO, Healthy People 2010, and the

American Nurses Association have identified the goals of increasing identification and prevention of violence against women.

Patrick Stewart talks about Domestic Violence

Domestic Violence

• A pattern of coercive behavior and methods used to gain and maintain power and control over another in an adult intimate relationship

• Can include: Psychological, physical, or sexual abuse or threats of physical or sexual violence

• Psychological abuse includes:• Emotional abuse, Isolation, Obfuscation, Using others, Male

privilege, Economic abuse, Coercion threats and Intimidation.

• Typically begins slowly and subtly. The woman may not recognize that she is in an abusive relationship.

Domestic Violence

• Contributing Factors:• Childhood experiences, Male dominance in family,

Marital conflict, Unemployment/low socioeconomic status, Traditional definitions of masculinity.

• The Cycle of Violence• Tension-building phase (power & control)• Acute battering incident: triggered by external event or

internal state. Unpredictable & destructive.• Tranquil phase: “honeymoon period”. Promises never

to do it again.

Domestic Violence: Nursing ConsiderationsUniversal screening of all female clients (Figure 9-2, Pg. 185)

• Private, safe place, confidentiality. Use calm, reassuring tone & watch non-verbal cues.

– "Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone?"

– "Within the last year, has anyone forced you to have sexual activities?"

Know cues of abuse:• *Hesitation in providing details about an injury; defensive injuries;

*delayed reporting of symptoms or injuries; *pattern of injury consistent with abuse such as multiple injury sites, scars or evidence of old injuries that have healed; *inappropriate explanation for injuries; *inappropriate affect *vague complaints; *lack of eye contact; *signs of increased anxiety in presence of batterer.

Domestic Violence--Interventions

Stress/Safety — "Do you feel safe in your relationship?”

Afraid/Abused — "Have you ever been in a relationship where you were threatened, hurt or afraid?”

Friends/Family — "Are your friends or family aware that you have been hurt? Could you tell them, would they be able to

give you support?“

Emergency Plan — "Do you have a safe place to go and the resources you need in an emergency?"

Domestic Violence--Interventions• Do not tell abused woman what to do. Help her recognize

her options and resources and make her own decision.• Self-Care Teaching:

• Women should have an exit or safety plan:• Pack change of clothes, toilet articles, extra set of keys for

herself & kids to store at friend’s or neighbor’s house.• Ask neighbor to call police if violence begins• Have money, identification, and financial records on hand• Plan where she will go and identify family & friends who can

help• Have emergency, hotline, police, shelter numbers

Domestic Violence: physical, sexual or emotional abuse

• Low birth weight 1.5 X more likely• 3-fold higher risk of being victims of

attempted/completed homicide• More likely to deliver by cesarean• More hospitalizations for maternal complications

– kidney infection

– premature labor

– trauma due to falls or blows to the abdomen

Domestic Violence- Incidence

• 1 in 12 pregnancies• Up to 20% in some studies• Often begins or escalates in pregnancy• Unintended pregnancy: 3 fold risk of abuse• More common than preeclampsia or gest diabetes• Infrequently screened for in office• Screening barriers

Human Reproduction Reproductive System Chapter 10

• Intrauterine Development• Week 5: primitive gonadal tissue• Week 7 or 8: differentiation begins in males

• Primitive testes--testosterone• Week 10: ovaries in females

• Fetal oogenesis: girls born with all their eggs• Week 12: external genitals visible

Puberty• Hypothalamus: gonadotropin releasing hormone

(GnRH)• Anterior pituitary: follicle stimulating hormone (FSH) &

luteinizing hormone (LH)• Production of androgen (testosterone) and estrogen

hormones by gonads• Growth spurt & secondary sexual characteristics (1-2

years before)• Sudden surge of estrogen in females produces menarche:

first menstruation (9-15 years of age)• First nocturnal emission in males (10-17 years of age)

Internal Female Reproductive Organs

Vagina• Hollow, musculomembranous canal that

extends from external vulva to uterus• Walls contain folds/rugae--expandable• Functions: a) passageway for sperm & fetus, b)

provides passage for menstrual blood flow, c) protects against infection from pathogenic organisms

• Acidic (pH 4-5) during reproductive years

Female Reproductive Organs:Uterus

• Hollow, muscular, thick walled organ shaped like upside-down pear, 6-8 cm long, 5 cm wide and 2.5 cm deep

• Body (top, includes fundus), isthmus (between body and cervix), cervix (lowest part)--2-5 cm long

• 3 layers of tissue: endometrium, myometrium, perimetrium

• After childbirth, the uterus never returns to its pre-pregnant size

Female Reproductive StructuresFallopian Tubes

• Smooth hollow tunnel for movement of ova to uterus• Ampulla (longest segment) most common site of

fertilization• Lining of tubes composed of mucus membrane which

contain mucus-secreting and ciliated cells which move ovum. Tubes also have muscular layer for peristalsis.

• Function-direct pathway that exists from the external organs through the vagina to the uterus and tubes to peritoneum so there is possibility of infection (peritonitis).

Reproductive System

Ovaries 2 almond-shaped glandular structures located close

to and on both sides of the uterus in the lower abdomen

Function: • produce, mature & discharge ova; • secrete estrogen and progesterone; • initiate and regulate menstruation.

Female Reproductive StructuresPelvis

• Supports and protects the reproductive and other pelvic organs

• Divided into the false pelvis and true pelvis.• False pelvis supports the uterus during the late

months of pregnancy and aids in directing the fetus into the true pelvis for birth

• True pelvis most important for birth. Consists of the inlet, pelvic cavity & outlet.

• The level of the ischial spines marks the midplane or midpoint of the pelvis

Pelvic Types

• Gynecoid: 50%. Adequate dimensions for birth

• Android: Male type. 20%. Inadequate outlet

dimensions for birth. C-section may be required. • Anthropoid: 25%. Adequate dimensions for birth.

• Platypelloid: 5%. Outlet may be inadequate (anterior-posterior dimension). May need c-section.

A B

DC

Female Reproductive Structures Breasts

• glandular, fibrous & adipose tissue.• Milk glands of the breasts divided into 15-24 lobes

separated by adipose & fibrous tissue. All glands produce milk.

• Nipple--erectile tissue. Surrounded by areola. Tubercles of Montgomery secrete lubricant when baby suckles.

• Suckling --stimulation of 1) the anterior pituitary which releases prolactin to produce

milk and 2) the posterior pituitary which releases oxytocin for milk

ejection.

Menstrual Cycle• Approx. 28 day cycle, 2-8 days of bleeding, average blood

loss: 25-60 mL.• Starts with 1st day of period

2 cycles: ovarian and uterine• Ovaries: Sensitive to lutenizing hormone (LH) &

follicle stimulating hormone (FSH)• Follicular & luteal phases• stimulation/maturation/ovulation

• Uterus: Sensitive to estrogen & progesterone• Menstrual, proliferative & secretory ischemic phases

Ovaries---Follicular Phase• Hypothalamus releases gonadotropin-releasing hormone

(GnRH) through the portal system to the anterior pituitary system to trigger release of FSH & LH

• FSH stimulates growth of egg follicle• Estrogen is produced after increase in LH• Surge in LH triggers ovulation• Follicle ruptures and releases an ovum into the

peritoneal cavity• http://youtube.com/watch?v=QkY7Xowg8Bw

•

OVARIAN CYCLE

UTERINE CYCLE

Ovaries---Luteal Phase

• Begins with ovulation. Ends with the onset of menses.• Corpus luteum (the follicle after ovulation) produces

estrogen and progesterone• ↑ estrogen & progesterone inhibit secretion of FSH and

LH (suppressing new follicular growth) & prepares/maintains endometrium of uterus

• If no fertilization, corpus luteum degenerates (8-10 days after ovulation) ↓ estrogen and progesterone levels

• When estrogen and progesterone decrease, the endometrium breaks down and menstruation begins.

Key Points of Menstrual Cycle

• Menstrual Phase is 2 to 8 days of bleeding• Body temperature drops slightly then rises (0.5-1

degree) around ovulation• When FSH rises it means the beginning of a new

cycle• LH surge stimulates ovulation and development

of corpus luteum• *Ovulation 14 DAYS before next menses

Key Points of Menstrual Cycle (Continued)

• Follicle is replaced by corpus luteum• Corpus luteum secretes progesterone and

estrogen• Progesterone (“pro-gestation”) prepares

endometrium for pregnancy• With no fertilization, corpus luteum degenerates--

progesterone & estrogen fall and menstruation and cycle begin again

Critical ThinkingThe nurse is reviewing documentation of a 15-year-old girl who reported that she has no pubic or axillary hair and has not yet experienced growth of her breasts. The nurse should explain to the client she probably lacks which hormone?

A)Testosterone B) Progesterone C) Estrogen D)Prolactin

Critical Thinking• A woman telephones the clinic to say that it has been six weeks

since her last menstrual period, but that her home pregnancy test was negative today. She asks, "Do you think I could be pregnant?" After determining that the test was performed correctly, what would be the nurse's best reply?

A) "You might be. If you haven't started your period in one week, you should repeat the test and call the clinic again."

B) "You may have an ectopic pregnancy. You should be seen by a doctor in the next few days."

C) "You probably are. There are a lot of false-negative results with these tests."

D) "Probably not. These tests rarely give a false-negative result." •

Critical Thinking

• A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6° C (1.0° F) for the past 36 hours. This most likely indicates that:

A) Menstruation is about to begin. B) Ovulation will occur soon. C) Ovulation has occurred. D) She is pregnant and will not menstruate. •