1. Nancy Pares, RN, MSN Metro Community College

2.  Apply basic knowledge of healthy maternal newborn care (recall from PN year)  Describe ethical and legal issues of maternal newborn nursing, current legislation and community resources available.  Demonstrate appropriate therapeutic communication and assessment of high risk pregnancy.

3.  Context ◦ Who is involved, what is the setting ◦ What other information is needed ◦ What personal beliefs of the nurse may impact the situation  Clarification of the issues ◦ What are the ethical issues ◦ Who should decide the issue  Identification of alternatives and potential outcomes

4.  Ethical reasoning ◦ What ethical theories have bearing on the situation ◦ Should some theories be given greater weight in the decision making process ◦ What legal or social constraints are factors ◦ What obligations might be present in the role of the nurse

5.  Resolution ◦ What is the best action in this situation ◦ What strategy should be used to carry out this action  Evaluation ◦ What were the outcomes ◦ Should this same action be used in the future for similar dilemmas

6.  Professional Nurse  Certified Registered Nurse  Nurse Practitioner  Clinical Nurse Specialist  Certified Nurse Midwife

7.  Religion and social beliefs  Presence and influence of the extended family  Socialization within the ethnic group  Communication patterns  Beliefs and understanding about health and illness  Permissible physical contact with strangers  education

8.  Standards of care: ◦ Minimum criteria for competent, proficient, delivery of nursing care  Institutional policies  Ethical implications  Scope of practice ◦ Defined by state Nurse Practice Act  laws

9.  There was a duty to provide care.  The duty was breached.  Injury occurred.  The breach of duty caused the injury (proximate cause).

10.  Divergence between rights of mother and rights of fetus: ◦ Mother may refuse fetal intervention. ◦ Fetal intervention may be forced on mother.  Fetal research: ◦ Therapeutic vs. non-therapeutic

11.  Intrauterine fetal surgery: ◦ Therapy for anomalies incompatible with life ◦ Health of the mother and fetus is at risk ◦ Surrogate, frozen embryo, ◦ Female circumcision

12.  Abortion ◦ Can be performed until point of viability ◦ After viability, if mother’s health in jeopardy  Nursing role ◦ Have right to refuse to assist ◦ Responsible for ensuring a qualified replacement is available

13.  Infertility  Human stem cells  Cord blood  Maternal refusal for c/del  Maternal refusal for fetal surgery

14.  Womens’ health standards by Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)  State Boards  Individual facilities policy

15.  A holistic interpersonal approach  Adequate documentation  Communication  Updated and realistic policies and procedures  Appropriate delegation  Question deviations from the standar  Follow chain of command

16.  Transforms research findings into clinical practice: ◦ Efficiency improvement ◦ Better outcomes ◦ Quality improvement

17.  Identify vulnerable periods during which malformations of various organs may occur and describe the resulting anomalies.  Describe the function and structure of the placenta during intrauterine life. (review PN year)

18.  Mitosis: ◦ Exact copies of original cell  Meiosis: ◦ Production of new organism

19.  Deletion ◦ Loss of chromosome material  Translocation ◦ Misplacement  Nondisjunction ◦ Chromosomes don’t separate correctly  Karotype ◦ Chromosomal make up of an individual Mosaicism two or more genetically different cell populations in an individual

21.  Interphase  Prophase  Metaphase  Anaphase  Telophase

22.  First division: ◦ Chromosomes replicate, pair, and exchange information. ◦ Chromosome pairs separate, and cell divides.  Second division: ◦ Chromatids separate and move to opposite poles. ◦ Cells divide, forming four daughter cells.

23.  Ovary gives rise to oogonial cells.  Cells develop into oocytes.  Meiosis begins and stops before birth.  Cell division resumes at puberty.  Development of Graafian follicle.

24.  Production of sperm  First meiotic division: ◦ Primary spermatocyte replicates and divides.  Second meiotic division: ◦ Secondary spermatocytes replicate and divide.  Produce four spermatids.

26.  Uniting sperm and ovum form a zygote  Ova are fertile for 12 to 24 hours  Sperm are fertile for 72 hours  Takes place in the ampulla of fallopian tube

27.  Capacitation: ◦ Removal of plasma membrane and glycoprotein coat ◦ Loss of seminal plasma proteins  Acrosomal reaction: ◦ Release of enzymes ◦ Allows entry through corona radiata

29.  Zone pellucida blocks additional sperm from entering  Secondary oocyte completes second meiotic division ◦ Forms nucleus of ovum  Nuclei of ovum and sperm unite  Membranes disappear  Chromosomes pair up

30.  Fraternal: two ova and two sperm  Identical: single fertilized ovum - Originate at different stages

31.  Cleavage  Blastomeres form morula  Blastocyst: - develops into embryonic disc and amnion  Trophoblast: - develops into chorion

32.  Occurs 7 to 10 days after fertilization  Blastocyst burrows into endometrium  Endometrium is now called decidua

33.  Primary germ layers: ◦ Ectoderm ◦ Mesoderm ◦ Endoderm

34.  Metabolic and nutrient exchange  Maternal portion: ◦ Decidua  Fetal portion: ◦ Chorionic villi  Fetal surface covered by amnion

35.  Chorionic villi form spaces in decidua basalis  Spaces fill with maternal blood.  Chorionic villi differentiate: ◦ Syncytium: outer layer ◦ Cytotrophoblast: inner layer  Anchoring villi form septa

37.  Body stalk fuses with embryonic portion of the placenta  Provides circulatory pathway from chorionic villi to embryo: ◦ One vein  Delivers oxygenated blood to fetus: ◦ Two arteries

39.  Nutrition  Excretion  Fetal respiration  Production of fetal nutrients  Production of hormones

40.  Beginning development of GI tract  Heart is developing  Somites develop—beginning vertebrae  Heart is beating and circulating blood  Eyes and nose begin to form  Arm and leg buds are present

41.  Trachea is developed  Liver produces blood cells  Trunk is straighter  Digits develop  Tail begins to recede

42.  Eyelids are closed  Tooth buds appear  Fetal heart tones can be heard  Genitals are well-differentiated  Urine is produced  Spontaneous movement occurs

43.  Lanugo begins to develop  Blood vessels are clearly developed  Active movements are present  Fetus makes sucking motions  Swallows amniotic fluid  Produces meconium

44.  Subcutaneous brown fat appears  Quickening is felt by mother  Nipples appear over mammary glands  Fetal heartbeat is heard by fetoscope

45.  Eyes are structurally complete  Vernix caseosa covers skin  Alveoli are beginning to form

46.  Testes begin to descend  Lungs are structurally mature

47.  Rhythmic breathing movements  Ability to partially control temperature  Bones are fully developed but soft and flexible

48.  Increase in subcutaneous fat  Lanugo begins to disappear

49.  Skin appears polished  Lanugo has disappeared except in upper arms and shoulders  Hair is now coarse and approximately 1 inch in length  Fetus is flexed

50.  Quality of sperm or ovum  Genetic code  Adequacy of intrauterine environment  Teratogens

51.  Maternal effects: ◦ Malnutrition ◦ Bone-marrow suppression ◦ Increased incidence of infections ◦ Liver disease  Neonatal effects: ◦ Fetal alcohol spectrum disorders (FASD)

53.  Seizures and hallucinations  Pulmonary edema  Respiratory failure  Cardiac problems  Spontaneous first trimester abortion, abruptio placentae, intrauterine growth restriction (IUGR), preterm birth, and stillbirth

54.  Decreased birth weight and head circumference  Feeding difficulties  Neonatal effects from breast milk: ◦ Extreme irritability ◦ Vomiting and diarrhea ◦ Dilated pupils and apnea

55.  Maternal effects: ◦ Poor nutrition and iron-deficiency anemia ◦ Preeclampsia-eclampsia ◦ Breech position ◦ Abnormal placental implantation ◦ Abruptio placentae ◦ Preterm labor

56.  Maternal effects: ◦ Premature rupture of the membranes (PROM) ◦ Meconium staining ◦ Higher incidence of STIs and HIV  Fetal effects: ◦ IUGR ◦ Withdrawal symptoms after birth

57.  Marijuana: difficult to evaluate, no known teratogenic effects  PCP - maternal overdose or a psychotic response  MDMA (Ecstasy) - long-term impaired memory and learning

59.  Identify tests used to detect abnormalities, fetal well being and infertility management.  Discuss age related considerations of pregnancy.  Explain the nursing process as it relates to maternal fetal medical conditions.

60.  Favorable cervical mucus  Clear passage between cervix and tubes  Patent tubes with normal motility  Ovulation and release of ova

61.  No obstruction between ovary and tubes  Endometrial preparation  Adequate reproductive hormones

62.  Normal semen analysis  Unobstructed genital tract  Normal genital tract secretions  Ejaculated spermatozoa deposited at the cervix

63.  Ovulation  Cervix  Uterine structures  Tubal patency  Semen analysis

65.  Ovulatory: ◦ Pharmacologic treatment ◦ Donor oocytes  Cervical: ◦ THI, IVF, GIFT

66.  Uterine/Tubal: ◦ IVF, GIFT ◦ Donor oocytes or gestational carrier  Sperm: ◦ THI, IVF, GIFT ◦ Micromanipulation

68.  Marriage may be stressed  Relationship affected by intrusiveness  Guilt  Frustration  Anger  Shame

69.  Loss of control  Feelings of reduced competency and defectiveness  Loss of status and ambiguity as a couple  A sense of social stigma  Stress on the personal and sexual relationship  A strained relationship with healthcare providers

70.  Counselor  Educator  Advocate

71.  Maternal age 35 or over  Family history: ◦ Known or suspected Mendelian genetic disorder ◦ Birth defects and/or mental retardation

72.  Previous pregnancies: ◦ Previous child with chromosomal anomaly ◦ Previous child with metabolic disorder ◦ Two or more first trimester spontaneous abortions

73.  Parental genetics: ◦ Couples with a balanced translocation ◦ Couples who are carriers for a metabolic disorder  Abnormal MSAFP  Women with teratogenic risk

74.  Multigenerational  50% chance of passing on the gene  Males and females equally affected  Varying degrees of presentation  Diseases ◦ Achondroplasia ◦ Marfans ◦ Neurofibromotosis

75.  Achondroplasia ◦ Most common dwarfism, lifespan and IQ WNL  Marfans ◦ Connective tissue disorder, triad of ocular, skeletal and CV alterations  Neurofibromotosis (Von Recklinhausen) ◦ Soft tumor development of peripheral nerves

77.  Carrier parents  25% chance of passing on abnormal gene  25% chance of an affected child  If child is clinically normal, 50% chance child is carrier  Males and females equally affected  Diseases: CF, Sickle Cell, PKU, Tay Sachs

79.  No male-to-male transmission  50% chance carrier mother will pass the abnormal gene to sons (affected)  50% chance carrier mother will pass the abnormal gene to daughters (carrier)  Diseases: Hemophilia A, Duchennes MD, Trisomies, Klinefelters, Turner’s Cri du chat, Fragile X

81.  Genetic ultrasound  Genetic amniocentesis  Chorionic villus sampling  Percutaneous umbilical blood sampling  MSAFP

83.  Educate about tests  Provide support  Refer for counseling  Resource during and after counseling

84.  Identify the maternal fetal effects of TORCH (toxoplasmosis, other, rubella, cytomegalovirus, herpes) infections and the corresponding nursing interventions.

85.  Toxoplasmosis  Rubella  Cytomegalovirus  Herpes simplex virus  Group B streptococcus  Human B-19 parvovirus

86.  Retinochoroiditis  Convulsions  Coma  Microcephaly  Hydrocephalus

87.  Congenital cataracts  Sensorineural deafness  Congenital heart defects

88.  Neurologic complications  Anemia  Hyperbilirubinemia  Thrombocytopenia  Hepatosplenomegaly  SGA

89.  Preterm labor  Intrauterine growth restriction  Neonatal infection

90.  Respiratory distress or pneumonia  Apnea  Shock  Meningitis  Long-term neurologic complications

91.  Spontaneous abortion  Fetal hydrops  Stillbirth

92.  Discuss pathophysiology, treatment and nursing interventions for pregnant women with: ◦ Cardiac Disease, Chorioamnionitis, Gestational trophoblastic disease, diabetes, Rh sensitivity, pregnancy induced hypertension and HELLP syndrome, HIV, hyperemesis gravidarium.

93.  Endocrine disorder of carbohydrate metabolism  Results from inadequate production or utilization of insulin  Cellular and extracellular dehydration  Breakdown of fats and proteins for energy

94.  Carbohydrate intolerance of variable severity  Causes: ◦ An unidentified preexistent disease ◦ The effect of pregnancy on a compensated metabolic abnormality ◦ A consequence of altered metabolism from changing hormonal levels

95.  Early pregnancy: ◦ Increased insulin production and tissue sensitivity  Second half of pregnancy: ◦ Increased peripheral resistance to insulin

96.  Hydramnios  Preeclampsia-eclampsia  Ketoacidosis  Dystocia  Increased susceptibility to infections

97.  Perinatal mortality  Congenital anomalies  Macrosomia  IUGR  RDS  Polycythemia

98.  Hyperbilirubinemia  Hypocalcemia

99.  Assess risk at first visit: ◦ Low risk - screen at 24 to 28 weeks ◦ High risk - screen as early as feasible

100.  Age over 40  Family history of diabetes in a first-degree relative  Prior macrosomic, malformed, or stillborn infant  Obesity  Hypertension  Glucosuria

101.  One-hour glucose tolerance test: ◦ Level greater than 130-140 mg/dl requires further testing  3-hour glucose tolerance test: ◦ GDM diagnosed if 2 levels are exceeded

102.  Maintain a physiologic equilibrium of insulin availability and glucose utilization  Ensure an optimally healthy mother and newborn  Treatment: ◦ Diet therapy and exercise ◦ Glucose monitoring ◦ Insulin therapy

103.  AFP  Fetal activity monitoring  NST  Biophysical profile  Ultrasound

104.  Assessment of glucose  Nutrition counseling  Education about the disease process and management  Education about glucose monitoring and insulin administration  Assessment of the fetus  Support

105.  Maternal complications: ◦ Susceptible to infection ◦ May tire easily ◦ Increased chance of preeclampsia and postpartal hemorrhage ◦ Tolerates poorly even minimal blood loss during birth

106.  Fetal complications: ◦ Low birth weight ◦ Prematurity ◦ Stillbirth ◦ Neonatal death

107.  Prevention and treatment: ◦ Prevention - at least 27 mg of iron daily ◦ Treatment - 60-120 mg of iron daily

108.  Maternal complications: ◦ Nausea, vomiting, and anorexia  Fetal complications: ◦ Neural tube defects  Prevention - 4 mg folic acid daily  Treatment - 1 mg folic acid daily plus iron supplements

109.  Maternal complications: ◦ Vaso-occlusive crisis ◦ Infections ◦ Congestive heart failure ◦ Renal failure

110.  Fetal complications include fetal death, prematurity, and IUGR.  Treatment: ◦ Folic acid ◦ Prompt treatment of infections ◦ Prompt treatment of vaso-occlusive crisis

111.  Treatment: ◦ Folic acid ◦ Transfusion ◦ Chelation

112.  Asymptomatic women - pregnancy has no effect  Symptomatic with low CD4 count - pregnancy accelerates the disease  Zidovudine (ZDV) therapy diminishes risk of transmission to fetus  Transmitted through breast milk  Half of all neonatal infections occurs during labor and birth

113.  Intrapartal or postpartal hemorrhage  Postpartal infection  Poor wound healing  Infections of the genitourinary tract

114.  Infants will often have a positive antibody titer  Infected infants are usually asymptomatic but are likely to be: ◦ Premature ◦ Low birth weight ◦ Small for gestational age (SGA)

115.  Counsel about implications of diagnosis on pregnancy: ◦ Antiretroviral therapy ◦ Fetal testing ◦ Cesarean birth

116.  Congenital heart disease  Marfan syndrome  Peripartum cardiomyopathy  Eisenmenger syndrome  Mitral valve prolapse

117.  Rheumatoid arthritis  Epilepsy  Hepatitis B  Hyperthyroidism  Hypothyroidism  Maternal phenylketonuria

118.  Multiple sclerosis  Systemic lupus erythematosus  Tuberculosis

119.  Tubal damage  Previous pelvic or tubal surgery  Endometriosis  Previous ectopic pregnancy  Presence of an IUD  High levels of progesterone

120.  Congenital anomalies of the tube  Use of ovulation-inducing drugs  Primary infertility  Smoking  Advanced maternal age

121.  Methotrexate  Surgery

123.  Assess the appearance and amount of vaginal bleeding  Monitors vital signs  Assess the woman’s emotional status and coping abilities  Evaluate the couple’s informational needs.  Provide post-operative care

124.  Vaginal bleeding  Anemia  Passing of hydropic vesicles  Uterine enlargement greater than expected for gestational age  Absence of fetal heart sounds  Elevated hCG

125.  Low levels of MSAFP  Hyperemesis gravidarum  Preeclampsia

126.  D&C  Possible hysterectomy  Careful follow-up

128.  Monitor vital signs  Monitor vaginal bleeding  Assess abdominal pain  Assess the woman’s emotional state and coping ability

129.  Control vomiting  Correct dehydration  Restore electrolyte balance  Maintain adequate nutrition

130.  Assess the amount and character of further emesis  Assess intake and output and weight.  Assess fetal heart rate  Assess maternal vital signs  Observe for evidence of jaundice or bleeding  Assess the woman’s emotional state

131.  Preeclampsia-eclampsia  Chronic hypertension  Chronic hypertension with superimposed preeclampsia  Gestational hypertension

132.  Maternal vasospasm  Decreased perfusion to virtually all organs  Decrease in plasma volume  Activation of the coagulation cascade  Alterations in glomerular capillary endothelium  Edema

133.  Increased viscosity of the blood  Hyperreflexia  Headache  Subcapsular hematoma of the liver

136.  Small for gestational age  Fetal hypoxia  Death related to abruption  Prematurity

137.  Monitoring for signs and symptoms of worsening condition  Fetal movement counts  Frequent rest in the left lateral position  Monitoring of blood pressure, weight, and urine protein daily  NST  Laboratory testing

138.  Bed rest  High-protein, moderate-sodium diet  Treatment with magnesium sulfate  Corticosteroids  Fluid and electrolyte replacement  Antihypertensive therapy

139.  Scotomata  Blurred vision  Epigastric pain  Vomiting  Persistent or severe headache  Neurologic hyperactivity

140.  Pulmonary edema  Cyanosis

141.  Assess characteristics of seizure  Assess status of the fetus  Assess for signs of placental abruption  Maintain airway and oxygenation  Position on side to avoid aspiration  Suction to keep the airway clear

142.  To prevent injury, raise padded side rails  Administer magnesium sulfate

143.  Hemolysis, elevated liver enzymes, low platelets ◦ Hypertension and proteinuria may or may not be present ◦ 90% present with symptoms before 36 wks gest. ◦ All with HELLP should deliver

144.  Rh – mother, Rh + fetus  Maternal IgG antibodies produced  Hemolysis of fetal red blood cells  Rapid production of erythroblasts  Hyperbilirubinemia

146.  After birth of an Rh+ infant  After spontaneous or induced abortion  After ectopic pregnancy  After invasive procedures during pregnancy  After maternal trauma

147.  Mom is type O  Infant is type A or B  Maternal serum antibodies are present in serum  Hemolysis of fetal red blood cells

148.  Incidence of spontaneous abortion is increased in first trimester  Insert nasogastric tube prior to surgery  Insert indwelling catheter  Encourage patient to use support stockings  Assess fetal heart tones  Position to maximize utero-placental circulation

149.  Greater volume of blood loss before signs of shock  More susceptible to hypoxemia with apnea  Increased risk of thrombosis  DIC  Traumatic separation of placenta  Premature labor

150.  Psychological distress  Loss of pregnancy  Preterm labor  Low-birth-weight infants  Fetal death  Increased risk of STIs