Child-bearing
“Birth” N370
September 13, 2019
“Childbearing is the most consistent of human events. Male and female
alike, we have all been gestated inside a woman's body. As a
phenomenon, childbearing is seemingly eternal and universal, yet like
no other it highlights the gender divide, the singularity of individual
experience and sociocultural diversities.”
Joan Raphael-Leff
Introductions…..
Where were you
born?
The…Syllabus…
syl·la·bus \ ˈsi-lə-bəs
Definition
1 : a summary outline of a discourse, treatise, or course of study or of examination requirements
• The Syllabus has the course schedule – I won’t make edits on this
document during the term.
• Use Sakai for most current information on weekly content,
preparation and assignments – any updates to the schedule, readings,
assignments will be here
• you won’t have to always pull up syllabus to be sure nothing’s changed
• It contains contact information for all the N 370 Faculty
• Pay attention to when assignments are due. Assume late assignments
won’t be accepted
• Review syllabus; Key Assignment…....\N370 Key Course Doc
Women’s Health
and
Maternal/Child
Nursing
…holistic care of women throughout the lifespan
… care of women, infants and their families during
child-bearing cycle
What do statistics tell us about the CHILD-
BEARING population?
National Vital Statistical Reports Nov 7, 2018
Current Trends & Stats
BIRTH RATE
• Number of live Births per 1000 of
population
GENERAL FERTILITY RATE
Understanding • Number of live Births per 1000 women
between ages 15 – 44
the Stats
TOTAL FERTILITY RATE
• Average number of children a woman would
bear during her lifetime, if her childbearing
were to conform to her age-specific fertility
rate every year between 15 - 44
Live Births
and Fertility
Rates US
1970 - 2017
General Fertility Rate 2017 60.3 Births per 1000 (ages 15-44)
3rd year in a row decreasing rate across all races
Geographic variance:
Utah < 1 in 5 births (18.5%)
Louisiana, Mississippi, New Mexico > 50%
Trends
Age & Marital Status
Birth Rates for Women in 40’s with continuous rise since 1985
Births for women > age 50 stayed essentially stable – 840 births in 2017
States with increased preterm birthrates:
Arkansas, Kansas, Maryland, Missouri, Montana, Oklahoma, Oregon, Texas
States with decreased preterm birthrates:
New Jersey, Rhode Island
Delivery by
Gestational
Age 2015-
2017
Preterm Birth Rate with slight rise, consistent trend over past 3 years
Data not specific for singleton VS multiple gestations
Women > age 40 more than twice as likely to have C-section (48.2%)
than women under age 20 (20.1%)
C-section rate with overall decrease for women ages 20 – 39, but…
C-section rate lowest ages 20-24 (25.9%), increasing to highest ages 35-39 (40.2%)
Cesarean
Births
2017 C-section rates by State
(Retrieved from [Link] 9/12/2019)
22.5-26.5 (Idaho)
26.9-29.9 (Wash)
30-31.6 (Calif)
31.8-34.1 (Oklahoma)
34.2-37.8 (Texas)
Percentage of
Women Smoking
During Pregnancy
by Race
Smoking during pregnancy by age:
< 20 * 8.2%
20-24 * 9.9%
35-39 * 4.4%
40-54 * 3.5%
Maternal Mortality
• A pregnancy-related death is
defined as the death of a woman
while pregnant or within 1 year of
the end of a pregnancy –regardless
of the outcome, duration or site of
the pregnancy–from any cause
related to or aggravated by the
pregnancy or its management, but
not from accidental or incidental
causes.
Retrieved from: [Link]
Maternal Mortality rates by Race 2011 - 2015
• 42.8 deaths per 100,000 live births for black non-Hispanic women
• 32.5 deaths per 100,000 live births for American Indian/Alaskan Native
non-Hispanic women
• 14.2 deaths per 100,000 live births for Asian/Pacific Islander non-Hispanic
women
• 13.0 deaths per 100,000 live births for white non-Hispanic women
• 11.4 deaths per 100,000 live births for Hispanic women
Retrieved from [Link]
Cause of Pregnancy Related Deaths
Infant
Mortality
2006 Data
Selected
Countries
Worldwide
Infant
Mortality
2012
Any thoughts
on how Birth
data informs
your nursing
practice?
Conception
So what really happens?
• Pre-puberty
• Puberty
• Early Adulthood
• Peri-menopause
• Menopause
• Ovulation
• Estrogen – progesterone
• Condoms
• Birth control pills
• IUD’s
• PCOS
In consideration of •
•
Endometriosis
Pelvic Inflammatory Disease
conception … •
•
Hysterectomy
Sexual abuse
• Drug addiction
• Religion
“Yay” or “Yikes”
What’s going on “behind the scenes”?????
A “Recipe” for Pregnancy – what do you
need?
Uterus…hormones…egg…sperm…
Conception
“…formation of the zygote…”
(Lowdermilk pp 265)
Implantation & Placenta
Development
• Chorion -
• fetal side of the placenta; develops major
umbilical blood vessels
• Amnion –
• covers the umbilical cord & the chorion on
the fetal side of placenta
The Placenta – a
most AMAZING temporary organ!
• Uterine capillaries are tapped by growth of chorionic villi
• Endometrial spiral arteries fill with maternal blood
• Layers develop
• Outer syncytium and inner cytotrophoblast
• Third layer develops and divides decidua – development
of15-20 cotyledons – each its own functional unit
• And….Wha-lah!
• Embryonic blood circulating between embryo & chorionic villi
• Oxygen and nutrients flow to embryo
• Waste and CO2 flow to mom…
• Pretty cool!
Think about the placenta over time…
Functioning placenta is vital to maintain
pregnancy
• Hormones
• Human chorionic gonadotropin (hCG)
• Have you heard of this hormone?
• What is it most commonly used for?
• Human chorionic somatomammotropin (hCS)
• Stimulates maternal metabolism to supply nutrients to growing fetus
• Progesterone
• Maintains stability of the endometrium, decreases uterine contractility
• Estriol
• Stimulates uterine growth and placental blood flow
• Circulatory function…
• directly related to maternal circulation…
• How would the following influence fetal growth and development?
• Hypertension?
• Hypotension?
• Maternal position?
• Uterine contractions?
• Where does Amniotic Fluid come from?
Amniotic • Initially produced by maternal blood
Fluid… the • Increased by fetal respiratory and GI
secretions
‘sea of life’? • At 11 weeks fetal urine adds to the volume
• (WOW peeing by 11 weeks!)
• Amniotic fluid functions
• Provides fluid for fetus to drink
• Cushions and protects fetus
• Cellular source for fetal testing
And…the
fetus
develops
1. Prenatal Question and Answer identified as
increasing your patient’s risk (write down the text of
the question AND your patient’s answer)
Next Week’s 2. What is the implied risk to pregnancy? What
is a possible pregnancy outcome related to the
Assignment…. identified risk? (you may need to do a little research to
answer this question – provide your reference)
Prenatal Risk
3. In your role as an RN, what education/health
promotion would you provide for this patient?
Time for a
break….
N370 Women’s Health Presentation
September 13, 2019
(can write down names of everyone in your
group, date, etc)
Infertility
• Scenario One • Scenario Two
Since you’re
a nurse….? • You’re taking care of a 60-year-old
woman in the hospital being • You are at a neighborhood
gathering. Your friend from
treated for pneumonia, she’s
going home today. As you are two doors down pulls you
talking with her, she says… aside, and says…
• “Since you are a nurse, can you • “Since you’re a nurse, I know I
Consider tell me what I should do? My son
and daughter-in-law talked about can talk to you. My husband
and I have been trying to
these having children within a couple of
years of marriage – now its been
4 years and no grandchildren. I
have a second child. It will be
his first, our son is from my
scenarios don’t know how to bring it up
without offending them. What
first marriage. I am worried I
can’t get pregnant. I just need
should I say? What should I do?”
to talk to someone I can
trust.”
Defining Infertility: • WHO defines Infertility as a “disease” – an
impaired function resulting in disability
Failure to establish • Infertility may be also referred to as
pregnancy after 12 “subfertility”
months of regular • Infertility is NOT the same as Sterility
and unprotected • Sterility is a PERMANENT state of infertility
intercourse
• Vander Borght M1, Wyns C2. Fertility and infertility: Definition and [Link] Biochem. 2018 Dec;62:2-
10. doi: 10.1016/[Link].2018.03.012. Epub 2018 Mar 16.
• Conception is dependent on several factors:
• Ovum developed and released via ovulation
• Intact HPA axis to support hormone
development and function
Pathophysiology • Patent fallopian tube to allow passage of ovum
and sperm
is dependent on • Cervical mucus pH of 7+ to support sperm
the underlying viability and mobility
• Sperm in adequate numbers, with normal
etiology morphology and motility
• Intercourse at a time when there is an ovum
ready for fertilization
• Uterus with proper shape and healthy
endometrium to support implantation
Etiology
Female Factors
• Infrequent ovulation
• Intense exercise • Fallopian tube & pelvic
• Eating disorders adhesions
• Stress • Pelvic inflammatory disease
• Elevated prolactin levels • chlamydia or gonorrhea
• Breast-feeding • Adhesions from endometriosis
• Polycystic Ovary Syndrome • Scarring from prior surgery
• Appendectomy
• Aging oocytes
• Uterine anomaly
• Impacts implantation
Etiology
Male Factors
Conditions leading to low or no Erectile dysfunction
sperm in the semen
Varicocele May be due to cardiovascular disease, substance
Undescended testicle use (i.e. alcohol), psychological issues, drug side
effects (SSRI)
Retrograde ejaculation
Opioid drug use (decreases testosterone levels)
Recognize sensitivity and intimate nature of the
history questions
Infertility
Initial
Assessment
– obtaining
the history Careful overall health history – questions involve
aspects of health for BOTH partners, not just the
woman
Reproductive history Endocrine Psychosocial
•onset of menses; current •Diabetes? Thyroid? Pituitary •Relationship? Substance use?
menstrual pattern; prior adenoma? Anxiety? Religious or cultural
pregnancies? Miscarriage? considerations impacting Medications
Termination? couple’s understanding of
infertility? Sexual practice?
Test (Female & Male) Comments
Ovulation Detection (F) Ovulation detection kits; basal body temp charts;
Infertility – Evaluation cervical mucus changes
RN Role; patient support &
education, assisting with Hormones (F) Prolactin, thyroid (can be drawn anytime)
examination & procedures progesterone, FSH, estradiol (drawn in
relationship to timing in menstrual cycle)
Ultrasound (F & M) (F) Transvaginal – assesses uterine structure;
ovarian cysts
(M) Scrotal – assess for varicocele, spermatic
cord abnormality
Hysterosalpingogram (F) X-ray using dye to establish patency of tubes &
shape of inner uterine cavity
Hysteroscopy (F) Scope inserted through cervix for direct
visualization of uterine cavity
Laparoscopy (F) Scope inserted intraperitoneally; assess external
to uterus – endometriosis, adhesions, polycystic
ovaries
Semen analysis (M) Quantity & quality of sperm
• PSYCHOSOCIAL • NONMEDICAL
Infertility • Address feelings/emotions • Lifestyle changes
Interventions • Develop stress management • Lowering scrotal
strategies temperature
• Relationship issues? • Avoid lubricants that may
Psychosocial • May have additional stress if impact sperm viability
& Nonmedical same –sex couple • Improve nutrition
• Weight loss OR weight
gain
• Timing of intercourse
• Adequacy of intercourse
penetration
• MEDICAL • ASSISTED REPRODUCTIVE
Infertility • Correct underlying pathophysiology
TECHNOLOGY
• Treat infections
Interventions • Address scarring/adhesion
• Intrauterine insemination
• In Vitro fertilization (IVF-ET)
• Hysteroscopy, laparoscopy,
hysterosalpingogram • Gamete intrafallopian transfer &
• Treat underlying endocrine Zygote intrafallopian transfer
(GIFT & ZIFT)
Medical & problem
• DM – glycemic • Oocyte donation
control/weight loss
Assisted • PCOS - metformin
• Euthyroid
• Embryo donation
• Surrogate mother
Reproductive • Pituitary adenoma –
bromocriptine lower
• Therapeutic donor insemination
prolactin levels
Technology • Ovarian stimulation – clomiphene
most commonly used medication
• What is your response to the opening scenarios?
• What do you say to the 60 yo hoping to be a
grandma; your neighbor hoping for a second child?
• What issues do you anticipate arising if treatment is
initiated?
Consider for
• When you discuss consideration of adoption?
discussion
• How do your own religious and/or cultural practice
impact your role in support/education/assisting with
infertility treatment?
For Next Week
• Complete the assignments in Sakai
• Read chapters
• I will have sign up sheet for Group Presentation
Topics
• (groups of 6, one group of 7)
• Dysmenorrhea
• Pelvic floor disorders
• Abnormal uterine bleeding
• PMS
• Reproductive cancers
• Breast conditions
• Menopause
• Sexually transmitted infections
