THE FAMILY AND CULTURE Importance of Nursing Roles - competentand aware when be culturally -educate and apply healthy providing care behaviours Families never forget Nurses during childbearing Empowerment is a central issue Introduction to Family, Culture, Community, and Home Care The composition, structure, and function of the Canadian family has changed dramatically in recent years. Significant barriers exist in accessing needed services. Nurses must become culturally aware in order to recognize and reduce or eliminate health disparities. The Family in Cultural and Community Context Defining family Basic structural unit within a community Assumes most of responsibility for: Socialization of its members Transmitting cultural background Core values Traditional Nuclear - - - family says iti s is undever the client Family No clear traditional Extended Blended -Single - Parent Theoretical Approaches to Understanding Families Remember they are there to helpform our practice guidelines Theories for Maternal-Child Nursing Reva Rubin – Maternal identity and the maternal experience Ramona Mercer – Transitions in a woman’s Life Regina Lederman – Psychosocial adaptation in pregnancy – Assessment of seven dimensions of maternal development - - Folle Acid critical spine, Vulnerable Populations of Women Adolescent girls 35years Minority women Older women starts at 35 years (ovaries decline) Incarcerated women Migrant/refugee women Homeless women Homeless families Rural versus urban community settings Cultural sensitivity and compassion Awareness of family and social stressors Treat with dignity and respect Helps woman reconnect with social support system Rubin'sMercer made a theory about becoming mother becomes pregnant beginning when a old is considered late pregnancy ovaries since the begin to decide. itis essential the a mother thing tohave with prenatal learly pregnancy nervous - from system (first30 the and the anys) World Health Organization Report for April 2005 WHO report for expectation for making pregnancy safe Prevent unwanted pregnancies Prenatal Care Provide social support and legal protection Family Assessment Appropriate framework for a perinatal nurse is one that is a health-promoting rather than an illness-care model. Use family assessment tool: Calgary Family Assessment Model (CFAM) Structural Developmental b e outi n the community Functional i n women wanting to there is a major shift · 48-hours hospital in the -24-hours hospital in the for - Income birth midwives As nurses for - CFAM heIDS in 8-section natural birth understanding issues from differentprespectives The Family in Cultural and Community Context Family Genogram-Family tree format depicting relationships of families over at least three generations Genogram tells you about specific family history you about should know Care of the Woman at Home - Perinatal Services Best delivered by an interprofessional team Home visits are an integral part of community health nursing Home care agencies often coordinate perinatal care Nursing Considerations Nursing assessments Medications Skills necessary Verbal and written patient education · Include the rightpeople high Make note of risk in the team pregnancies no longer able - give to birth a athome with midwife POSTPARTUM PHYSIOLOGIC CHANGES & NURSING CARE OF THE FAMILY DURING THE POSTPARTUM PERIOD The Postpartum Period The Postpartum Period- the interval between the birth of the newborn and the return of the reproductive tract to the non-pregnant state. the cantapeVfOweeKsfOrSterUStoGobacKNnormalstate star of giving Dirm/pregna re The Fourth Stage of Labour of labours fourth stage to post-partum reffered understand how to breathe to ·baby getting - · - Mom getting Assess the notbeing used to fundus to be and function outside ofwound pregnant firm post-partum, toavoid hammornage Involution process is the return of - · With involution, itgets shrink over and over to The Involution Process · Involution is the return of the uterus to a non-pregnant state. At term, the uterus is approximately 11 times its prepregnant weight. At the end of the third stage of labour, the uterus weighs about 1000g. It is located midline in the abdomen about 2 cm, below the umbilicus. · cramps women give to helps oxytocin frequently - Terms and Definitions you give birth by continuing tocontract advil, ibuprofen to occur, needed in order for birth feed lose women who breast - after a weeks can take upt o with motrin, contractions stimulates oxytocin state => which managed can be the uterus normal backto weightfaster preventhemorrhage check - which is any we have to funds the the fundus, relative to Mustvoid before assessing the Autolysis The self-destruction of excess hypertrophied tissue. umbilicus (ie I below 0) Subinvolution Fundus should be from The failure of the uterus to return to its pre-pregnant state. after birth Each day fundus goes down a finger length Hemorrhage uterus is still enlarged People still look pregnantrightafter since the For a healthy woman, hemorrhage is the most dangerous potential complication in the postpartum period. normal state will naturally go backto Extra tissue located in the uterus, which - - - - - Postpartum Homeostasis - through a process is a major thing Bleeding we look for srasing the to post-partum, which can lead to Retorning tohomeostasisaftergivingbinfeed divers the breastrightaway -Putbaby to natural secretion of oxytocin stimulates the - - Breastfeeding The more you skin -Skin. To stimulate breastfeeding, is good for bonding's lang more breastm ilk the breasts will be produced temperature regulation Breastfeeding Women who plan to breastfeed are encouraged to put the baby to breast as soon as possible, preferably in the delivery room > stimulates the release of oxytocin Afterpains The periodic relaxation and vigorous contraction of the uterus, are intensified by breastfeeding or the administration of exogenous oxytocin. - offer mom pain medication as frequently aspossible as long as contractions continue and breastfeeding can cause pain. hemmornage Uterine Healing Placenta - · Vterus is has a elevated spot where itused to be, and tiny muscle that goes only after backto normal giving hypertrophy tissue will be destroyed birth Lochia Lochia is the term used to describe the postbirth uterine discharge. pregnancy is -lochia serosa nextphase - - Scantsmall 12 the amount especially wantt omonitor - look for the presence of a (moderate (excessive -if Cervix you soak a pad in a 15 min brown/pinkish day 4-22-darker or clear colour yellowish discharge) hours you are colour post-partum indicates that blood is blood dot which period period blood lasts from Glbd => The 3-4weeks after Lochia red (lasts 3-4days) bright - after Ischia Rubra right - pooling hemorrhaging The cervix is soft immediately after birth. Within 2 to 3 postpartum days the cervix shortens and becomes firm and regains its form. The portion of the cervix that protrudes into the vagina (ectocervix) appears bruised, and has some small lacerations which makes it a potential site for infection. The supporting structure of the uterus and vagina may be injured during childbirth and contribute to gynecologic problems in later life. - The cervixonly takes a couple days to go backto normal but it will never look the same after kind ofpeople with small lacerations - bearing - Endocrine System drinkenough water and be on strol softeners, and pushed to put much pressure. down becomes easier and prevents so women are Kegal often excersises -Once too encouraged placenta baby. It active so will look peristalsis and -> pee and purse over and over is gone, there is a rapid decrease in placenta hormones significantlyby the one week mark Everything wome getbaby blues-estrogen levels decreasesbreasts enlarge - Diaphoresis - - - physically a drops - - having legs become very is whole process swollen triggered by getting ovulation, immunity, metabolism Prolactin levels in blood increase progressively throughout pregnancy > rid of placenta the mammary glands Ovulation Ovulation occurs as early as 27 days after birth in non-lactating women, with a mean time of about 70 to 75 days. The mean time to ovulation in women who breastfeed is about 6 months. you can get pregnantwhile breastfeeding are getting ready ovulation is the process in your body where you - - - Distasis Recti - hard for muscles to to drop an egg mend back The muscles of the abdomen remain relaxed for about the first two weeks postpartum. It takes about 6 weeks for the abdominal wall to return to its pre-pregnancy state. Urinary System About 2 to 8 weeks is required for pregnancy induced hypotonia, and dilation of the ureters and renal pelvis to return to the prepregnant state. The breakdown of excess protein in the uterine muscle cells also results in a mild proteinuria for 1 to 2 days after childbirth in about 50% of all women. Ketonuria may also occur during this time period. Trauma to the urethra and bladder may occur during the birth process as the infant passes through the pelvis, so the bladder may be hyperemic and edematous. Clean catch or catheterized specimens before and after birth may reveal hematuria. - - Protein have line is an alarm to in the Ketones may be during prognancy butis presenta s well since the otheros is broken down mildly normal post-partum Bowel Function A spontaneous bowel movement may be delayed for up to 3 days after childbirth Operative vaginal births and anal sphincter lacerations are associated with an increased risk of postpartum anal incontinence. Pelvic floor exercises should be encouraged. Breasts As lactation is established a mass or filled milk sac may be felt in the breast. This duct will shift position from day to day. Colostrum is very good for the baby since it is full of nutrients iscalories - Colostrum Colostrum loosens mucus and acts as a laxative, therefore it aids in the clearing of both the respiratory and GI tracts in the newborn. It also decreases the likelihood of hypoglycemia and reduces the severity of physiologic hyperbilirubinism in the newborn. Engorgement Engorgement can occur in both breastfeeding and non breastfeeding woman. Engorgement or breast swelling is caused by increased blood and lymph supply to the breasts before lactation. Maternal Blood Volume The changes in blood volume after birth depend on the amount of blood loss during childbirth and the amount of physiologic edema present. Pregnancy induced hypervolemia allows most women to tolerate a considerable blood loss during childbirth. 500mL for Postpartum Physiologic Changes 12 - vaginal birth for c-section The uterus no longer supply anything needs to placenta since itis to the gone Fundal Height Prior to checking the fundus, request that the client empty her bladder. A woman should then lay on her back with the head flat and knees flexed. If the fundus is not firm, massage it gently Assessment First hour after birth BP, pulse, and respirations are monitored every 15 minutes. Temperature is monitored at the beginning and at the end of the recovery period or as necessary. Second hour after birth BP, pulse, and respirations are usually monitored every 30 minutes. Fundal height, lochial flow, and the perineum would also be checked at the same times while monitoring the vital signs. Turn client onto her side to assess an episiotomy site and/or hemorrhoids. What to Expect Postpartum Pulse rate, stroke volume, and cardiac output increase throughout pregnancy Remain elevated or increase for about 30 to 60 minutes as the blood that was shunted through the uteroplacental circuit returns to the maternal systemic venous circulation. Intense tremors that resemble shivering from a chill. May be a small transient increases in both systolic and diastolic blood pressure lasting about 4 days after birth. Respiratory function returns to the non-pregnant state by about 6 weeks postpartum. The diaphragm descends, the normal cardiac axis is restored, and the point of maximum impulse normalizes. slightincrease in vitals present after giving birth /Upto4days postpartom - Potential Complications Infections Puerperal Infection Encourage women to change peri pads after each trip to the washroom. Apply pad from front to back. Women should wash hands before and after using washroom or handling peri pad. It is common for WBC to be elevated for the first 10 to 12 days post delivery. This leukocytosis may obscure diagnosis of acute infection. Monitor for an elevated temperature higher than 38 degrees, on 2 or more consecutive days (not counting the first 24 hours post delivery). Criteria for Early Discharge~ Mother Criteria for Early Discharge~ Baby ASSESSMENT AND HEALTH PROMOTION The Menstrual Cycle Involves: Ovulation Menstruation Ovaries produce: Estrogen- female charecteristics Progesterone- decreases contractility of uterous during pregnancy Prostaglandins- stimulate contraction Occurs at 4 Levels: 1 Hypothalamic-Pituitary level 2 Ovarian level 3 Endometrial level 4 Cervical level - - Essentially one big cycle ovulation is discharge from -Menstration is shedding ·Menstoral has cycle Hypothalamic-Pituitary Level - - to produce follicles FSHstimulates ovaries cause ovulation help to FSH Lit acts With Ovarian Level - - - and menstural flow - - Once shedding During from - - and menstural begins bleeding the days, is (follicularssteal phases ovarywill grow The first day ofmenstural days estrogen cycle are 13-16 is start firstday of period (when you (hotdays to watch for levels decrease;increased levels of FSH 3, steady levels of LH initiate estrogen secretion by ovary follicular phase begins done estrogen then produce the for 72 hours sperm lives (day 1-5)-estrogen isprogesterone Menstural phase month phases counting) - every the Herus walls 4 Mostfertile - Menstrual phase (days 1 to 5) Follicular phase (days 6 to 14) Secretory phase (days 14 to 26) Ischemic phase (days 27 to 28) of in two Oocyte grows in 2 phases: Follicular phase – (day 1 to 14) follicle matures Luteal phase – (day 15 to 22) corpus luteum develops from ruptured follicle Endometrial Level which the ovaries and progesterone LIis decrease, FHincreases, and steady which will the ovaries trigger estrogen secretion implant-favourable for egg to to Follicular phase, estrogen increases and causes proliferation of the endometrial lining get ready FSHwill stimulate gratian follicle, and will decrease before ovulation. environment. Follicle will secrete estrogen, for fertilization of the sva, itconcession does and progesterimproduction increases is, the endometrium is prepared Secretoryphase During notoccur, estrogen ischemic phase occurs and cortos lutern degenerates - estrogen decreases Cervical Level - - - - - caused by the of estrogen ovulating increase When a women starts are Middle one is what you wantw hen you Good marker that tells you Spinbarkeit when you are trying togetpregnant orciating again Reasons for Entering the Health Care System Preconception counseling and care Pregnancy Menstrual problems Well and sick care Fertility control and infertility Termination of unwanted pregnancy Health Assessment - - watch for USE - assess and Bimanual - inside One hand irregularities isone outside POSTPARTUM COMPLICATIONS Postpartum Hemorrhage (PPH) Defined as: (1) cumulative blood loss ≥1000 mL or (2) bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process regardless of type of birth Early, acute, or primary PPH occurs within 24 hours of the birth Late or secondary PPH occurs more than 24 hours but less than 6 weeks after the birth -Up to 1000mL for - - - a c-section can cause hypovolemia can happen once 6- Week follow women is a discharged up appointmentwill UP Etiology and Risk Factors Uterine Atony flaciduterus thatis Placental Complications Lacerations of Genital Tract Hematomas Inversion of the uterus Subinvolution of the uterus · - - - If a woman keeps bleeding Laseration thatis Hematoma Inversion properly not uterus to 6 take place week mark and contracting (getting not post-partom, inlunder traumatized of normal is we suspectthere is thatmayhave check for anytrauma blood loft over bleed fixed will continue to flow you and sits there can can mistaken itfor during birth bleed This can placenta pieces leftbehind. and occurred become an emergency situation. GreatestR ISI locked area butc an occur typical is notvery Postpartum Hemorrhage: Interprofessional Care Management -startwith palpation, if you can'tfind it- massage ~ Full assessmentt o find out -Medical - - managementgo Surgicallygo If itkeeps in and do going you will in whati s happening o ut. and scrape it DHR have to proceed with a hysterectory isremove entire uterus Hemorrhagic (Hypovolemic) Shock Coagulopathies - · don't reallyknow the Idiopathic means you the lifespan ofplatters Antibodies decrease cause and you do notd otproperly Venous Thromboembolic Disorders - - Differentdegrees/types Encourage earlyambulation Postpartum (Puerperal) Infections The presence of a fever of 38 C (100.4 F) or more on 2 successive days of the first 10 postpartum days (not including the first 24 hours after birth) Postpartum Infections PREEDAMONT - edema, Pain, redness, measurementodour, echymosis, drainage, aryhthemia, NBC, Temperature PHYSIOLOGIC AND BEHAVIOURAL ADAPTATIONS OF THE NEWBORN Neonatal Period Stages of Transition to Extrauterine Life - Cyanosis the to fact isextremetics is normal Second Period of Reactivity Occurs 2 to 8 hours after birth Lasts from 10 minutes to several hours Tachycardia, tachypnea occur Increased muscle tone Improved skin color Mucous production Meconium typically passed Physiologic Adaptations Respiratory System Initiation of breathing Establishing Respiration Signs of respiratory distress Acrocyanosis - once blood supplyis forced to begin breathing How is Breathing Initiated? Likely the result of a reflex Breathing is irregular and shallow once respirations are established…30-60 per minute with periods of apnea less than 15 seconds Apneic periods longer than 15 seconds should be evaluated. Signs of Respiratory Distress Nasal flaring Retractions Grunting with expirations Any increased use of the intercostal muscles Seesaw respirations A respiratory rate that is less than 30 or greater than 60 per minute with the infant at rest must be reported ·see-saw - respirations Abdomen's, is a sign chestrise opposity of a babystruggling to breathe for a long period of time Pulmonary Surfactant Pulmonary surfactant is an oily substance produced by the cells lining the alveoli. It reduces surface tension, therefore requiring less pressure to keep the alveolus open. Surfactant develops as the infant develops in utero Fetal pulmonary maturity can be determined by examining the amniotic fluid for the L/S ratio and other phospholipid levels. For lung function is gas exchange fluid -> L ratio of1.2 at surfactantl evels through moms amniotic is way to assess a babies way of initiating respirations by looking born - - - - If this is off, we know when theyare babies respirations will notb e upto par We can increase primonarysurfactantin a babybefore theyare born with Physiologic Adaptations a steroid a babyunless in or (betamethazone dexamethazone concerned there we are is a cardiac problem is notmonitored Cardiovascular System Blood pressure Heart rate and sounds the NCU extremeties may be done in Upper and lower Blood pressure (dircomoral cyanosis) Blood volume Bluish colour to mouth can be veryconcerning Signs of Cardiovascular Problems Persistent tachycardia Persistent bradycardia Skin color: pallor, cyanosis Hematopoietic system to getrid ofbillyrupin Pooping helps Red blood cells within first24 hours if babyis saundiced Leukocytes concerning Platelets Blood groups Thermoregulation: the maintenance of balance between heat loss and heat production the baby) the first24-hours Hypothermia No neatl oss allowed within (cold-stressing their heat Heat loss hypother mid since they have a differentwayof maintaining (through Babies are more prone to Thermogenesis fatstore is deplated thata baby becomes stressed -> brown Hypothermia and Cold stress Anytime is the less brown fatavailable The less mature the baby Hyperthermia - - - - - - brown fatt - - - next - - - - to Baby will shiver helppreserve to loss more prone neat Pre-term babies are helppreserve is born to when Flexed position baby body temperature and is used as their blood is taken from out, sugar you stress a baby heat through Babies predominantlylose When their head wear energy for warmth throws ofmetabolic state hat) heati n bathing process them since theywill lose Cold Stress When the air temperature around the baby is cool, thermoreceptors in the skin are stimulated. Non- shivering thermogenesis is initiated and brown fat is burned for energy to keep the body temperature stable. This is the infant’s initial response. An infantwho has notvoided by24-hours mustb e assessed Renal System adequate fluid intake bladder distention Renal system restlessness, discomfort An infant who has not voided by 24 hours must be assessed born Fluid and electrolyte balance to breastonce they are You only have 30 min. to putbaby Signs of renal system problems Gastrointestinal System they fall asleep Feeding behavior is related to several things 6-8 wetdiapers for babies Breastfeeding is important in establishing the intestinal microbiome of the newborn fed babies will poopmore) 1-2 poop diapers (breast Digestion Stools Monitor fluid/electrolyte levels closely liver Feeding behaviors have very immature jaundice Signs of gastrointestinal problems risks to stopbleeding physiologicalvs. pathological noth ave enough clotting factor Hepatic System liver since itdoes is injections for newborns getvitamin Iron storage Vitamin 1) does notc ross the placenta Glucose Homeostasis K Fatty Acid Metabolism Breast milk does not contain vitamin Bilirubin Synthesis Jaundice - - Babies baseline tomp.should be 536.0 in order bathe to - · · · - - - - - - - - - Two Forms of Jaundice Related to Breastfeeding: of breastfeeding Breastfeeding-associated jaundice The lack of affectiveness Early-onset jaundice breastmilkgetting to baby Not enough Breast milk jaundice Dush more to feed more Late-onset jaundice - - - is whatc auses jaundice, breastfeeding not itself before Immune System Compared to adults, the immune response at birth is reduced, leading to increased susceptibility to pathogens Neonatal levels of circulating immunoglobins are low Many components of breast milk strengthen the neonate's immune system Risk for infection since Integumentary system ita ll awayI hearing testis always delayed birth Canal lobrications should notwash Vernix caseosa -> substance thatprotects baby through Milla are small white spots on face Sweat glands; milia occurs when baby is in for too long. Desquamation Desquamination, skin peeling usually Mongolian spots i s normal in babies ofc olour spot Mongolian Nevi: nevus flammeus and nevus vascularis Infantile Hemangioma Erythema toxicum Signs of integumentary problems w ill subside within 24-hours Reproductive system swelling due to hormones but Swelling of breast tissue & genitalia assess this at birth Need to Signs of Reproductive System Problems Ambiguous genitalia Hypospadias Undescended testes Inguinal hernias birth canal feel for frontals atb irth as some can shiftwhen being pushed through Must Skeletal System it Head and Skull for means late hair/dimples closed which Spine lookatbottom Spine Extremities Signs of Skeletal Problems Neuromuscular System Almost completely developed at birth Normal tremors, tremors (jitteriness) of hypoglycemia, and seizure activity must be differentiated Newborn reflexes - - - - - - - - Behavioral Characteristics Newborns progress through a hierarchy of behavioral developmental challenges: Sleep-wake states Sensory behaviors Response to Environmental Stimuli Temperament Habituation Consolability Cuddliness Irritability Crying itcan build upin ear NURSING CARE OF THE NEWBORN AND FAMILY Care Management: Birth Through the First 2 Hours Immediate care after birth Initial physical assessment Apgar Scoring Heart rate Respiratory rate Muscle tone Reflex irritability Generalized skin color 1 s,5min. If5min If 5min Mar the is better than min readingitis normal poores the outcome mark is lower the Permits a rapid assessment of the need for resuscitation based on five signs that indicate the physiologic state of the neonate These scores do not predict future neurologic outcome, but the 5 minute score does correlate with the degree of risk for neonatal morbidity and mortality Care Management: Birth Through the First 2 Hours -Period - where Whole baby is getting used to life outside of the uterus physical assessmenttakes place with baselines Classification of newborns by gestational age and birth weight Appropriate for gestational age (AGA) Large for gestational age (LGA) ways ofdocumentation Small for gestational age (SGA) 33 Care Management: Birth Through the First 2 Hours - - - - Gives you ways to testw here the Babies flexfor temperature Laugo-baby hair The score tells ending you baby is at, and you circle whatt he baby is able to as regulation now mature the baby is according to the - ways Guidelines term - they are responding that to tell you if you have a pre/post birth Babies ideally should be 37 weeks Gestational Age Assessment- Classification by Gestation if is Preterm or premature—born before completion of 37 weeks of gestation, regardless of birth weight Respiratory system mostvulnerable we give betame that one Late preterm—34 0/7 through 36 6/7 weeks baby is pre-term Early term—37 0/7 through 38 6/7 weeks Full term— 39 0/7 through 40 6/7 weeks Late term—41 0/7 through 41 6/7 weeks Postterm—42 0/7 weeks and beyond Postmature—born after completion of week 42 of gestation and showing the effects of progressive placental insufficiency - - Immediate Interventions Airway Maintenance Maintaining an Adequate Oxygen Supply Maintaining Body Temperature Eye Prophylaxis Vitamin K Prophylaxis Promoting parent-infant interaction Care Management: From 2 Hours After Birth Until Discharge Common Newborn Problems Birth injuries atleast every 8-12 hours -Assess for jaundice Retinal and subconjunctival hemorrhages Soft-tissue injuries: erythema, ecchymoses, petechiae hours If itis on a rise baby most come back within 12-24 Trauma secondary to dystocia cord I access through umbilicle Accidental lacerations Common Newborn Problems Physiologic problems Hyperbilirubinemia Assessment and screening Every newborn should be assessed for jaundice at least every 8 to 12 hours Therapy for hyperbilirubinemia Phototherapy Types of phototherapy Precautions Exchange transfusion Common Newborn Problems Hypoglycemia Infants at risk for hypoglycemia: preterm or late preterm; SGA or LGA; low birth weight; infants of mothers with diabetes; and infants who experienced perinatal stress such as asphyxia, cold stress, or respiratory distress Pre/post term babies are mosta trisk (over/under weight) Nurses should observe all newborns for signs of hypoglycemia to breast/feed How blood glucose-baby Laboratory and diagnostic tests irritation Universal Newborn Screening symptomsgitters, done after 24 hours Newborn Hearing Screening Screening for Critical Congenital Heart Disease (CCHD) hear - - - - - 3 ~ - screenfor heartdisensebylisteningto t Neonatal Pain after 24 hours) Neonatal responses to pain Most common sign is vocalization or cry Physiologic/autonomic responses pain is most obvious w/ Changes in heart rate i Vhystone pronounced Blood pressure Intracranial pressure Vagal tone Respiratory rate Oxygen saturation - Nonpharmacologic management Containment (swaddling) Nonnutritive sucking Oral glucose Skin-to-skin contact Breastfeeding Pharmacologic management Local and topical anesthesia Nonopioid analgesia Acetaminophen Opioid analgesia Morphine Fentanyl - - - - Give glucose to help boost serotonin baby is distractbaby less than 6 months old cannotreseve can give tylenol cryingselevated HRsa intracranial pressure from pain Ibuprofin (opioids ifnecessary) Doses of morfine for baby going through with draws from mon Discharge Planning and Parent Education To set priorities for teaching, the nurse follows parental cues. Knowledge deficits or gaps should be identified before beginning to teach. Temperature countdirty diapers Respirations Adequate feeding moisture is non-sunken fontanes membrams Feeding oral Ayuration Elimination no backs, toys in the crib Avoid SIDS - baby on Sleeping, Positioning and Holding Safe sleep positions Sudden infant death syndrome (SIDS) - - - - for rashes Rashes zinc cream Diaper Rash as breastm ilk changes Bowels change Other Rashes time to air out babies bom Clothing Tommy under Car Seat Safety - no more than 2 fingers car seatassessment Pacifiers Bathing Umbilicle cord falls 10 days after birth Umbilical Cord care Skin care Infant follow-up care Cardiopulmonary resuscitation Practical suggestions for first week at home Interpretation of crying and use of quieting techniques Recognizing signs of illness - - - - - Seatb elt TRANSITION TO PARENTHOOD Parent-Infant Contact Communication Between Parent and Infant The senses Touch Eye contact Voice Scent Entrainment Biorhythmicity Reciprocity and synchrony - Touch is a Smell - Eye - - is a for large factor large factor Three phases of maternal role attainment (Rubin, 1961) Becoming a mother (Mercer 2004; Mercer and Walker, 2006) Postpartum “blues” Postpartum depression (PPD) newborns of breastmilk smell sweetness for contacttakes several months sound by the Becoming a Mother - - - time Post-partum baby comes blues out, stay up baby they 2 to seeing clearly start to know more weeks - 3 days voice t o more need to talkabout is, and Becoming a Father Predictable phases of paternal transition: Enter parenthood with intentions of being an emotionally involved father Confronting reality, realizing the expectations were inconsistent with realities of life with a newborn during the first few weeks Working to create the role of an involved father Reaping rewards, the most significant being reciprocity from the infant, such as a smile Often receive less interpersonal and professional support compared with mothers Sibling Adaptation Reactions manifested in behavioral changes Involvement in planning and care Sibling Rivalry Acquaintance process The initial adjustment of older children to a newborn takes time, and parents should allow children to interact at their own pace rather than forcing them to interact Grandparent Adaptation NEWBORN NUTRITION AND FEEDING Recommended Infant Nutrition Benefits of Breastfeeding - Reduced risk of breast cancer and ovarian cancer for mothers Enhanced bonding and attachment Convenience Economic benefits Environmental benefits - - Infant Feeding Decision-Making Obstacles to Breastfeeding Employment Pumping Breastfeeding resources Infant formula marketing Lack of education Insufficient training of health care professionals - Encourage moons to breastfeed Immunoglobulins passed through Breast milk Deferring cancer (decreased preventovarians, breast to breast milk strengthen the babies immune risk system is nutrientr ich thoughttobe infantformula better for baby than breast m ilk Contraindications to Breastfeeding Galactemia baby - breakdown cannot cannotbe breastfed. - active Viruses, untreated TB, herpes the breastmilk Complex, intertwining network of milk ducts that transport milk from the alveoli to the nipple Anatomy and Physiology of Lactation - hears When mother down reflexis let the feed the baby ready to the milk baby crying, is produced, getting ismilk to grosses breast feed HIV cannot spots on breast, active Anatomy and Physiology of Lactation Lactogenesis Prolactin prepares the breast to secrete milk Supply-meets-demand system Oxytocin Milk ejection reflex (MER): let-down reflex Same hormone that stimulates uterine contractions during labor Mothers who breastfeed are at decreased risk for postpartum hemorrhage Nipple-erection reflex from lactose "liquid goldfirstfew days colostrom -> Anatomy and Physiology of Lactation - Contains many immunologically active, protective components: Main Immunoglobulin: IgA IgG, IgM, IgD, and IgE are also present Colostrum: more concentrated than mature milk and extremely rich in immunoglobulins Higher concentrations of protein and minerals but less fat than mature milk Will sustain the baby enough since iti s so nutrient rich Anatomy and Physiology of Lactation Care Management: Supporting Breastfeeding Mothers and Infants Breastfeeding Initiation Infants exhibit feeding-readiness cues Hand-to-mouth or hand-to-hand movements Sucking or mouthing motions Rooting reflex—infant moves toward whatever touches the area around the mouth and attempts to suck The ideal time to begin breastfeeding is within the first hour after birth Assessment of Effective Breastfeeding - - - - - How to assess thata seven or Breastshield Every baby is feeding higher-butisis mainly may be used for Frenulum-tongue Care Management: Supporting Breastfeeding Mothers and Infants diaper count. zero inverted flatnipple 4hours mom should be tie well besides the to address the ones that are feeding might need to be in the hospital, to catch cut if the baby any ofthese issues cannotsocks well antidepressent Mostmedications are contraindicated with breastfeeding, especially Medications medications than nom Alcohol –ok for half a beer to promote milk production milkrather for baby if they getsome breast More benificial Smoking -okay Caffeine Herbs and Herbal Preparations Information about the safety of medications and breastfeeding can be accessed through the Drugs and Lactation Database (LactMed) - - Common Breastfeeding Concerns Engorgement Sore nipples Insufficient milk supply Plugged milk ducts Mastitis - Fever/malais Potbaby in uprightposition when feeding Parent Education Burp baby w/ every feed. Readiness for feeding Feeding patterns Feeding technique Infants should be held for all feedings chemicals may be added Bottle should never be propped the baby as certain to feed to Need to meet the rightguidelines Common concerns Spitting up; burping Bottles and nipples Infant formulas (commercial formulas) Cow’s milk–based formulas Protein hydrolysate formulas Soy protein-based formulas, recommended for infants with galactosemia and congenital lactase deficiency Alternate milk sources such as goat's milk; skim or low-fat milk; condensed milk; or raw, unpasteurized milk from any animal source should not be fed to infants Formula Feeding - - - Formula Preparation Powdered formula: least expensive Concentrated formula Ready-to-feed: most expensive but easiest to use Vitamin and mineral supplementation Weaning Complementary Feeding: Introducing solid foods The AAP recommends introducing solid foods after 6 months of age Cultural beliefs and traditions affect complementary feeding practices Nurses and other health care professionals educate parents regarding complementary feedings MATERNAL AND FETAL NUTRITION Key Components of Preconception and Prenatal Nutritional Care Nutrition Assessment Diagnosis of nutrition-related problems Interventions Evaluation Nutrient Needs Before Conception - OCCUl - leastserious mostcommon is discovered onracerous for -Menin. - Myelo. - - - - this condition Very easily repairable mostserious Spine Closes over the cyst All moves fall into this area Nutrient Needs During Pregnancy Dietary reference intakes (DRIs) Energy needs Body mass index Weight gain Pattern of weight gain Hazards of restricting adequate weight gain Excessive weight gain Protein Fluids - Nutrient Needs During Pregnancy Minerals and Vitamins Fat and water-soluble vitamins Folate and folic acid Vitamin C Vitamin B6 Vitamin B12 Multivitamin-multimineral supplements during pregnancy Protein Increase needed - na/gra MuctivitaminscangreateffecttheA systememize gastric Alcohol and Substance Use Medications Alcohol no safe amountpermitted Smoking not OK Caffeine ok butnot large amounts -> causesvasoconstriction is, Herbs and Herbal Preparations Food Cravings PICA - - - trimester the minimizes blood flow across placenta upto Nutritional Care and Teaching - Adequate iron levels needed to rise it dilutes since blood volume continues body lailational anemia Dietary Lifestyle Choices: Implications for Pregnancy - iti s animal source Protein bestabsorbed when need to be consumed in high be levels to amounts adequate Fruits/Veggies Vegetarian and Vegan Diets Consuming a variety of different plant proteins—grains, dried beans and peas, nuts, and seeds—on a daily basis can provide all of the essential amino acids. - Hormonal Effects on Nutrition Progesterone > absorbed Relaxation of smooth muscle in GI tract which reduces motility leads to constipation buthelps get nutrient get Allows more nutrients to be absorbed ^ maternal fat deposition increase water holds itback - very importantto ^ renal Na+ excretion Increases urge to pee butestrogen Estrogen >Increased water retention hCG > Implicated in morning sickness - - Recommended Weight Gain Guidelines BMI Normal BMI Overweight Obese Underweight Weight Gain 25 – 35 lbs 15 – 25 lbs 15 lbs 27.5 – 40 lbs Pattern of Weight Gain 1st trimester 2nd & 3rd trimester 2 – 5 lbs (1 – 2.5 kg) ~ 1 lb/week Tissues contributing to maternal weight gain at 40 weeks gestation intake Nutritional Requirements in Pregnancy - are stored in Fat Soluble Vitamins SolDDVitamins - They are stored the body - where water excreted Kidneys liver and can be are in the toxic for the baby (A,K,E,D) Vitamin over supplementation may lead to vitamin toxicity > congenital anomalies!!! Nutritional Assessment Includes Fish Consumption & Pregnancy - - Fish is good source fish thathave low levels of ofOmega, importantto chose Health Canada encourages eat150 continue to women to a grams of fish week mercury salmon, trout, mack) Listeria & Food Safety - can cause brain damage Minimizing the Risk of Listeria Contamination *Read and follow all package labels and instructions on food preparation and storage. *To avoid cross-contamination, clean all knives, cutting boards and utensils used with raw food before using them again. *Thoroughly clean fruits and vegetables before you eat them. *Refrigerate or freeze perishable food, prepared food and leftovers within two hours. *Defrost food in the refrigerator, in cold water or in the microwave, but never at room temperature. *Keep leftovers for a maximum of 4 days, preferably only 2 – 3 days, and reheat them to an internal temperature of 74°C (165°F) before eating them. LABOUR AND BIRTH PROCESS Obstetric History Terms-GTPAL Factors Influencing the Onset of Labour - - Signs of Labour When the body reduces oxytocin stimulates contractions - - is MUCOUSDIG discharge lightening is one of the early 3 - - - True contractions Braxton nicks Bloody Labor and Birth Process in the upper area do not signs sign of labour as well-babies - earliestsigns few days before and one of the head begins to engage through birth the canal factors (ie. Warm blanket feel better when you implementalleviating contractions show is a Real labour contraction pain Umbilicus a can breathe better capillaries - progesteronesstartstowithdrawal are false contractions good thing, itis the onsetof uterus startt o burst. This is an in the is lower to upper back, radiates when the cervixstarts indication the woman is to dialate and all the starting to progress is polic area, false labour pain more above the Passenger The fetal skull is composed of two parietal bones, two temporal bones, the frontal bone, and occipital bone. The bones are united by membranous sutures: the sagittal, lambdoidal, coronal, and frontal. - The other bones can override on to allow the baby more flexibility to move down?Outof the mother. 8 months after birth Fetal Head Diameters - (baby) chin-to-chest baby - to come Do notneed out. The Diparietal ideally now more narrow to know diameters be positioned as it comes - is - through you want better the justknow how itshould canal birth come outof is most difficultpartto birthing canal. Passenger “Presenting Part” Presentation refers to the part of the fetus that enters the pelvic inlet first. There are three main presentations: Cephalic vaginal examination, feel for head Breech footing feetfirst or frank breach entire butwill feel sacrom) Shoulder you will feel scapula - - - - - Dreech'sshoulder are dangerous Cephalic is head down 90% labaVertexpresentation) is the same where the had is part Dresenting the - - Breeched, dangerous. More likely Shoulder-physician can do do to c-section -> Naton for placenta an extroversion where wrapping they change the position oft he baby - - - 7 cardinal movements of labour Happen in baby order while the General flexion 2) comes outduring birth. ofthe baby tarn Baby Start Fetal Lie Lie is the relation of the long axis of the fetus to the long axis of the mother. Longitudinal lie – the fetus’s spine is parallel to the mother’s spine Transverse lie – the spine of the fetus is at right angles to the spine of the mother. - long axis is their spines relative to each other fuxion we wantA-complete fuxion B > mocrate Fetal Attitude hyperfaxion Attitude is the relation of the fetal body parts to each other. Normally the back of the fetus is rounded, the chin is flexed on the chest, the thighs are flexed on the abdomen the legs are flexed at the knees, and the arms are crossed over the thorax. Do Fetal Position Position is the relation of the presenting part to the four quadrants of the mother’s pelvis. The first letter denotes the location of the presenting part in the right (R) or (L) side of the mother’s pelvis. The second letter stands for the specific presenting part of the fetus (O) occiput, (S) sacrum, (M) mentum or chin, (Sc or A) scapula or shoulder or acromion process. The third letter stands for the location of the presenting part in relation to the (A) anterior, (P), or (T) transverse portion of the mothers pelvis. - 2nd letter letter we wantocciputwill notknow this until we do vaginal examination isfind the presentation - - Bestposition is slae lying Supine can cause hypotension which results in a blood flow baby to Fetal Station Station is the relation of the presenting part of the fetus to an imaginary line drawn between the maternal ischial spines. The placement of the presenting part is measured in cms above or below the ischial spines. Engagement Engagement is the term used to indicate that the largest transverse diameter of the presenting part has passed through the maternal pelvic inlet into the true pelvis occurs in the weeks before labour for - engagement just a firsttime mother and often occurs as the labor Cardinal Movements of Labour- Passenger during llightening) or -Entering of the pelvis movement thatoccurs - - - Internal rotation happens rotate to - for diameters accommodate and Will nothave o-section iftoo tight Fontanels are helpful because they are flexible extends - crowning you will see around st is born there is extension rotation. 11-2min) for the next through they sitthere for a rest rest of baby) when the next largest piece of the baby head comes When the contractionsthats - begins - Head passes through pelvis;paby When head lightening occurs baby during decentby the - - labour (when when the restof the Then exposion baby comes out Passageway- The Bony Pelvis The passageway is composed of the mother’s rigid bony pelvis and the soft tissues of the cervix, pelvic floor, vagina, and the introitus (external opening of the vagina). The bony pelvis is formed by the fusion of the ilium, ischium, pubis, and sacral bones. The four pelvis joints are the symphysis pubis, the right and left sacroiliac joints, and the sacrococcygeal joint. The bony pelvis is divided into two parts by an imaginary line at the level of the inlet called the Linea Terminalis, the false pelvis above, and the true pelvis below. want to assess pelvis shape in advance The toe pelvis is involved in the birthing process -> - Obstetric Measurements- Pelvis Outlet - Truepelvis The - - - - inlet, midpelriss outlet justknow location of true pelvis;whatitdoes (birthing baby) inlet Upper border middle Mid rightin the snug passage outletlower border - - Pelvisshape makes a big difference body releases When you are close to being pregnant, the birthing) Pelvis Types side effecti s hands a fatmay relaxin which stretches ligaments (good for stay bigger post pregnancy Gynecoid – the classic female type, present in 50% of all women, usually supports spontaneous vaginal birth Android – the classic male pelvis, 20% of all women, heart shaped, may need assistance with forceps or suction during birth process, may require Csection. Anthropoid- oval shaped, 25% of all women, usually can deliver vaginally, may need slight assistance of forceps. Platypelloid - 5% of all women, flattened from to back, widest side to side, supports vaginal birth Soft Tissues of the Passageway Pelvic floor muscles t he help rotate baby draw baby out Powers Involuntary uterine contractions, called the primary powers, signal the beginning of labor. Once the cervix has dilated, the voluntary bearing-down efforts by the woman , call the secondary powers, augment the force of the involuntary contractions Primary Powers The primary powers are responsible for effacement and dilation of the cervix and descent of the fetus. Effacement of the cervix means the shortening and thinning of the cervix during the first stage of labor. The cervix is normally 2 to 3 cm long and about 1 cm thick. The degree of effacement is expressed in percentages from 0 to 100%. stage labour 1st 2nd stage is Birthing wall entire process soon getto100m. to means passed stalation. works to help baby by gravity descend. Long walks good too, you, and arvix Sex-sperm softens the Cervical Dilation Dilation of the cervix is the enlargement or widening of the cervical opening and the cervical canal that occurs once labor has begun. The diameter of the cervix increases from less than 1 cm to full dilation 10 cm When the cervix is completely dilated and effaced, it can no longer be palpated. Full dilation marks the end of the first stage of labour. Cervical Dilation Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, caused by the uterine contractions. During labor, increased intrauterine pressure exerts pressure on the cervix. When the presenting part of the fetus reaches the perineal floor, mechanical stretching of the cervix occurs. Stretch receptors in the posterior vaginal cause release of endogenous oxytocin that triggers the maternal urge to bear down (Ferguson Reflex) · can use foley catheter and scan-ifballoon comes outyou know inflate you are Secondary Powers Position of the Laboring Woman Maternal Position Cardiac output is compromised if the descending aorta and ascending vena cava are compressed during labor. “All fours” (hands and knees position) may be used to relieve backache if the fetus in in occipito-posterior position. This may assist in the anterior rotation of the fetus in cases of shoulder dystocia Positioning for Second Stage Labour Lithotomy-a supine position of the body with the legs separated, flexed, and supported in raised stirrups Semi-recumbent – can push coccyx forward causing reduction in pelvic outlet. Sitting or squatting – uterus moves forward and aligns the fetus with the pelvic inlet, increases the pelvic outlet Lateral – helps rotate fetus that is in posterior position, decreased force of bearing down som MAXIMIZING COMFORT FOR THE LABOURING WOMAN Approaches to Pain Management During Labour Non-Pharmacological Approaches to Pain Management Providing a supportive labour/birth environment Relaxation and breathing techniques Continuous Labour Support Counter pressure Therapeutic touch massage & Effleurage (light massage) Birthing ball Relaxing and Breathing Techniques Focusing and Relaxation Techniques Breathing Techniques Application of Heat and Cold Pharmacologic Pain Management Sedatives- To help calm and relax in early labour Nitrous Oxide- an odorless, tasteless gas — is a pain reliever that's inhaled. Administered through a hand-held face mask. Nitrous oxide takes effect within a minute. Anesthesia encompasses analgesia, amnesia, relaxation, and reflex activity Analgesia: the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness Systemic analgesia Nerve Block Analgesia and Anesthesia Local nerve block Spinal anesthesia Epidural General Anesthesia Care Management Informed consent for anesthesia Timing of administration Preparation for procedures Administration of medication Intravenous route Intramuscular route Regional anesthesia Safety and general care
