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Maternal Child Health Nursing

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Presentation on theme: "Maternal Child Health Nursing"— Presentation transcript:

1 Maternal Child Health Nursing
Module 3

2 objectives Discuss pregnancy and fetal well-being
Discuss pregnancy complications

3 Physiological changes of pregnancy
Uterus Hormones stimulate increased vascularity, growth of new muscle and tissue (hyperplasia) and growth of existing muscle and tissue (hypertrophy) Grows from 2 ounces (50 grams) to 2.2 pounds (1,000 grams); rises from low pelvis to base of ribcage Enlargement a “probable sign” of pregnancy Hegar’s sign: softening of isthmus, also “probable”

4 Physiological changes of pregnancy
Cervix Softening called “Goodell’s sign”, a probable sign of pregnancy Ovaries Suppressed ovulation Vagina Chadwick’s sign: blue, violet or purple darkening of vagina, cervix, perhaps vulva

5 Physiological changes of pregnancy
Breasts Hypertrophy of mammary glands Increased vascularization, size, pigmentation and changes in areolas and nipples Colostrum forms in late pregnancy and may leak even before birth of baby Need adequate support

6 Pregnancy: cardiovascular
FON p 792, box 25-5 10-15 bpm increase Blood pressure decreases slightly in second trimester and returns to pre-pregnancy levels in third Blood volume: 40%-50% increase H&H: decreased due to blood volume Increased RBC mass WBCs increase 2nd, 3rd trimesters Cardiac output: 30%-50% increase

7 Pregnancy: respiratory
FON p 792 box 25-6 Rate may increase 02 consumption 15%-20% greater Total lung capacity may be slightly decreased In 3rd trimester, high fundal position may make short of breath. Lightening refers to the baby’s drop into the pelvis before birth and often allows easier breathing

8 Pregnancy: musculoskeletal
Increased weight and outgrowth of womb alter mom’s posture Exaggerated spinal curves (lordosis): aching, numbness, weak upper extremities Estrogen and relaxin soften connective tissues, symphysis pubis and hip joints, allowing growth and change but also stretching supportive fibers

9 Pregnancy: gastrointestinal
Peristalsis slows Gas, constipation, abdominal distension and discomfort Hemorrhoids from constipation, pressure Iron supplements May have higher cholesterol, cholelithiasis

10 Pregnancy: urinary In first trimester, hormones and enlarging uterus irritate bladder -> frequency Later, weight of uterus puts pressure on bladder Kegels can help prevent urinary incontinence Ureter and kidney dilation, bladder trauma can lead to increased infections

11 Pregnancy: integumentary
Darkened pigmentation Areola, nipples, vulva, perianus, linea alba Linea nigra Darkening of areola may allow newborn to better visualize target area during breastfeeding Chloasma or butterfly Striae gravidarum: stretch marks Spider nevi, palmar erythema, hirsutism

12 Pregnancy: endocrine Elevated estrogen, progesterone
Triggered by HCG from corpus luteum weeks 1-10 Maintained by placenta thereafter Prevent follicle-stimulating hormone (FSH), luteinizing hormone (LH) and ovulation Prolactin, oxytocin Pituitary gland origin Role in contraction (oxytocin), breastfeeding (both)

13 Pregnancy: metabolism
Metabolism generally increases to meet energy needs of mother and fetus Affected by prenatal nutrient/energy state Maternal energy stores may be altered by larger baby Mom needs up to 500 extra Kcalories, depending on trimester or breastfeeding status Number of infants Underlying maternal needs

14 Signs of pregnancy Presumptive – possibly mean pregnancy Amenorrhea
Nausea, vomiting Frequent urination Breast changes Abdominal changes Quickening (16-18 weeks) Skin changes Chadwick’s sign

15 Signs of pregnancy Probable (indicate high likelihood)
Changes in reproductive organs (uterine enlargement with softening of isthmus (Hegar’s sign), cervix (Goodell’s sign) Ballottement (palpating presence of fetal by rebound) Positive pregnancy tests (accuracy depends on collection technique)

16 Signs of pregnancy Visualization of fetus X-ray or ultrasound
Positive Visualization of fetus X-ray or ultrasound Fetal movement observation by health care provider Auscultation of fetal heartbeat 10-12 weeks by Doppler/ultrasound 18 weeks fetoscope

17 Psychological adaptation to pregnancy
Developmental tasks Pregnancy validation Accepting the pregnancy (1-13 weeks) Fetal embodiment Woman thinks of herself as “mom” and thinks of the fetus as part of herself (14-27 weeks) Fetal distinction Mom prepares for delivery, thinks of fetus as separate from herself (28 weeks – delivery) Role transition Woman/wife/girlfriend -> Mom Partners’ tasks Similar transition to parent role

18 Factors: psychological response
Body image Financial situation Cultural expectations Status, work Emotional security Support from significant others

19 Prenatal education and care
Prenatal care Begins before conception and continues during pregnancy It may take weeks before a woman realizes she’s pregnant Neurological development significant in first few weeks Women not preventing pregnancy should prepare for it

20 Anticipatory guidance self-care
Pregnancy can be a great time to teach health promotion, as women often are eager to protect their pregnancies Pap smears, breast self exams Nurses can help women separate fact and fiction

21 Prenatal care: initial visit
History, demographics Estimated due date (EDD) Nagele's rule Start with first day of LMP, count back 3 months, add 7 days Most babies born 10 days before or after this date Useful if Mom’s menstrual cycle regular Gestation calculation wheel Two wheels preprinted with dates and events that can show EDD

22 Prenatal care: initial visit
Estimated due date (EDD) Woods Method or Nichols Rule Primigravida (28-day cycle): LMP + 12 mo – 2 mo and 14 days Multigravida (28-day cycle): LMP + 12 mo – 2 mo and 18 days Cycles >28 days: EDD + (days in cycle – 28 days) = new EDD Cycles < 28 days: EDD – (28 days-days in cycle) = new EDD Mittendorf’s Observations

23 Prenatal care: initial visit
Fundal height From weeks 18-30, the height of the fundus in centimeters about equal to weeks’ gestation Requires skill and experience for accuracy

24 Prenatal care: initial visit
Ultrasound High-pitched sound waves bounced off fetus and tissues are received back by monitor and made into pictures (sonogram) or pattern (FHR monitor) Doppler refers to a hand-held version that works similarly – picks up fetal heartbeat Fetal heartbeat Detected by auscultation (fetal stethoscope), Doppler or sonogram Quickening Mom feels baby’s movements – starts about weeks gestation

25 Prenatal care: physical exam
Vital statistics Are vital signs appropriate to trimester and general health? Head to toe exam Gives baselines and also opportunities to note changes Pelvic exam Screens and tests may be done, structural abnormalities noted and reassurances given

26 Descriptive terms Abortion : termination of pregnancy <20 weeks
Spontaneous: unintentional loss of pregnancy (miscarriage) Threatened: cramping, bleeding, spotting but closed cervix and no tissue passed Inevitable: S/S, cervix opens Incomplete: S/S, dilation, tissues passed Complete: S/S, tissues and fetus passed, cervix closes and bleeding stops Missed: fetus dies in utero but is retained, can lead to sepsis Recurrent: two or more abortions

27 Descriptive terms Induced abortion: intentional loss of pregnancy
therapeutic: to preserve health of mother Elective: reasons other than health of mother (fetal abnormality, social reasons) Gravida: pregnancy Nulligravida: never been pregnant Multigravida: pregnant more than once

28 Descriptive terms Para: birth Preterm: born at 0-36/6
Nullipara: never carried pregnancy past age of viability Multipara: more than one pregnancy past age of viability Preterm: born at 0-36/6 late preterm: 34-36/6 weeks Term: weeks Post term: 42 or more weeks

29 Defining parity FON p 788, box 25-5
G – gravidity: number of pregnancies, including present one T – term births: number of births at or after 37 weeks’ gestation P – preterm births: number of births before 37 weeks A – abortions : number of pregnancies interrupted before age of viability L – living children: not including present pregnancy

30 Screening tests Ultrasonography
High-frequency sound waves gestational age Presence of normal fetal development or abnormal developments Status and location of placenta and cord Maternal serum alpha-fetoprotein screen (msAFP) Can indicate possible presence of chromosomal problems (Down’s syndrome) if dates are correct Maternal blood test

31 Screening tests Chorionic villus sampling Amniocentesis
Genetic test of placental tissue Done at 8-12 weeks to avoid fetal injury Amniocentesis Done around 16th week to determine fetal status May be done later to determine lung maturity Non-stress test Fetal monitoring without added stimulus Contraction stress test Fetal monitoring after stimulating contractions; done after 32nd week

32 Screening tests MRI Biophysical profile Non-stress test results
Images soft tissues and blood vessels without use of contrast medium Clearer than ultrasound Biophysical profile Assessed fetal well-being by measuring Non-stress test results Fetal breathing movements Fetal muscle tone Fetal movements Amniotic fluid volume

33 Prenatal care: return visits
Subjective Objective blood pressures Weight Abnormal gain may mean increased fluid volume/edema Uterine size Measurements smaller or larger than expected for gestational age may indicate problem Edema Visible edema may indicate rising blood pressures

34 Prenatal care: return visits
Fetal heartbeat Is it within normal range for gestational age? By term, normal range will be about beats/minute Temporary increases/decreases normal with fetal activity Labs Blood: anemia, infection, etc Urine: infection, glucose/protein spilling Fetal position As baby nears 37th week of pregnancy, usually turns head down Head-down position best for vaginal birth Leopold’s maneuvers

35 Leopold’s maneuvers Abdominal palpation
Gently done – should not be uncomfortable or painful With practice, examiner can determine location of fetal head, buttocks and body position

36 Leopold’s maneuvers

37 Discomforts vs warning signs
Cause Interventions Client education Warning signs

38 Discomforts of pregnancy
FON p 792 Table 25-4 When evaluating complaints, consider stage of pregnancy, history, related activities Shortness of breath: 1st trimester vs 3rd Urinary frequency and urgency Normal or s/s possible UTI? Braxton-Hicks contractions vs labor contractions Edema Nausea/vomiting

39 Warning signs FON p 790 Box 25-9 Visual disturbances Headaches
Edema , rapid weight gain Pain s/s infection Vaginal bleeding, drainage Persistent vomiting

40 Warning signs (cont’d)
Muscular irritability or convulsions Absence or decrease in fetal movement Kick count: fewer than 10 movements in 2 hours should be evaluated

41 Pregnancy: self care Breast care Personal hygiene
Breast self-exam Support Personal hygiene Increased perspiration Safety, mobility and the bathtub Tub baths after cervical dilation Teaching about douching Interrupted flora

42 Pregnancy: self care Activity and rest Fatigue may limit
Should be able to talk during exercise Safety for changing balance 3rd trimester changes Non-contact activities Changes in rest and sleep patterns

43 Pregnancy: self care Nutrition Mercury (large predatory fish)
What not to eat Mercury (large predatory fish) Harmful bacteria and viruses Raw or undercooked fish, shellfish, meats, eggs, poultry, processed meats, refrigerated pates and meat spreads Pregnant women have less resistance to certain bugs like salmonella and listeria Stick to pasteurized foods (dairy, juices) Unwashed fruits and vegetables Large quantities of liver (too much vitamin A)

44 Pregnancy: self care What not to eat (cont’d) Too much caffeine
Any alcohol unless recommended by health care provider Some herbal teas and supplements

45 Pregnancy: self care Clothing Employment Travel Dental care
Sexual activity

46 Anticipatory guidance
Environmental hazards Discomforts Warning signs Nutrition Medications Pregnancy categories

47 Childbirth education classes
Fear-tension-pain syndrome (Grantly Dick-Read) Bradley (husband-coached) Lamaze (psychoprophyllaxis) Mongan HypnoBirthing (profound self-relaxation) Hospital routine classes Pregnancy and newborn care classes

48 Complications of pregnancy

49 Assessment: fetal well-being
Ultrasound Transabdominal Endovaginal Non-stress test Monitor FAST & VST Measure fetal response to acoustic stimulation Fetal biophysical profile Breathing, movement, tone, fluid assessment, reaction

50 Assessment: fetal well-being
Fetal movements 10 movements in 2 hours indicates fetal well-being Stimulate movement by eating, drinking Biochemical assessment (maternal blood test) msAFP: chromosomal Estriol: development Human placental lactogen: developmental

51 Assessment: fetal well-being
Amniocentesis 1st trimester: detect chromosomal problems 3rd trimester: fetal health, maturity Chorionic villi sampling 1st trimester: infection, cell abnormalities Contraction stress test How fetus responds to contractions

52 Assessment: fetal well-being
Electronic fetal monitoring External Ultrasound and transducer over abdomen Reflects FHR, cxns onto monitor screen Requires complex interpretation skills Internal Attaches to fetal scalp May give clearer FHR pattern Connects to same monitor Interpretation AWHONN

53 Hyperemesis gravidarum
Disorder distinct from “morning sickness” Vomiting causes electrolyte, metabolic, nutritional imbalances and dehydration Requires evaluation and care Rehydration, possibly IV nutrients Lab values reflect electrolyte, hydration status Nursing care: IV, medications, educate about disorder, medication side effects, fetal safety

54 Bleeding complications
Abortion/miscarriage Ectopic pregnancy Fertilized egg implants out of uterus, usually in fallopian tubes Life-threatening once fetus grows large enough to cause damage Hydatidiform mole Fertilized egg growing without nucleus or placenta Abnormally high HCG levels

55 Bleeding complications
Placenta previa Placenta growing too close to cervix Stress during pregnancy, labor and/or delivery breaks blood vessels Fetal hypoxia May resolve if uterine muscles pull placenta out of path as pregnancy grows Indication for C-section delivery if present at time of delivery Bright red blood, painless – after 20 weeks Sonogram: placenta location, fetal life

56 Bleeding complications
Abruptio placenta Premature placental separation Partial or total Risk factors: trauma, chronic HTN, PIH, DM, cocaine use, etc. S/S of total or severe partial: sudden severe abdominal pain, rigid abdomen Monitor FHR Emergency C-section required Sonogram: placental location, fetal life Avoid vaginal/rectal exam

57 Bleeding complications
Disseminated intravascular coagulation (DIC) Disrupted clotting cascade: the body’s response to bleeding overproduces clotting elements, tying up the supply in many tiny clots in small blood vessels. The clots obstruct blood flow and oxygenation of tissues, organs. The rest of the blood is free to bleed out Underlying disorders: abruptio placentae, incomplete abortion, HTN, infection, prolonged retention of dead fetus

58 Bleeding disorders DIC:
Bleeding in lungs: dyspnea, chest pain, restlessness, cyanosis, frothy and bloody mucus coughed up Excess bleeding from small wounds/sites IV sticks, B/P cuff petechiae, shave nicks, IM sites, catheter insertion, nosebleed, bleeding gums Labs: H&H (anemia), decreased fibrinogen and platelet counts, prolonged PT, PTT times noted. Tx: IV blood and clot components, 02 by face mask, woman on side Consider delivery

59 Bleeding disorders DIC Postpartum hemorrhage
Monitor: V/S, FHR, bleeding, I&O (renal status), status of underlying disorder and response to treatments May prepare for emergency C-section, advanced neonatal support and NICU care/transport Postpartum hemorrhage Excessive bleeding after delivery

60 Nursing care: bleeding complications
Stabilize bleeding IV fluids, fundal massage, treat hypovolemic shock Prepare for surgery if necessary Pain management Recognize and get help in emergency Post-operative care Teaching considerations: fertility, expectations, self- care, pregnancy progression

61 Pregnancy-induced hypertension
May occur during or after pregnancy Mild pre-eclampsia 140/90 B/P or increased >30 mm/Hg systolic/15 mm Hg/diastolic with previous normal B/P Edema: hands, face, ankles Weight gain up to 3 lbs/month (2nd trimester) and 1 lb/week (3rd trimester) Urine output at least 20.8 mL/hour (500 mL/24 hours)

62 Pregnancy-induced hypertension
Severe pre-eclampsia High B/P, edema also to abdomen and sacrum, dramatic weight gain, increased albuminuria, urine output drops below 500 mL/24 hours Eclampsia Seizures, coma Magnesium sulfate May be used IV with careful control of amount Calcium gluconate should be kept at bedside to treat toxicity

63 Pregnancy-induced hypertension
HELLP Syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets Development of pre-eclamptic and eclamptic states Pain in RUQ, lower chest, epigastric, severe edema May have normal blood pressures Hypoglycemia very dangerous for mother May need blood transfusion Prepare for needs of preterm newborn

64 Nursing care: HTN Monitor V/S, FHR, pregnancy status, medication side effects Give antihypertensives, supportive care IV, pre/post C-section care Do not give pain medication if unexplained pain present until assessment done by healthcare provider to avoid masking problem

65 Maternal diabetes mellitus
Type 1 or 2 before pregnancy Gestational diabetes develops during pregnancy Effects of pregnancy on diabetes: poorer glucose control, can only use insulin Effects of diabetes on pregnancy: UTIs, poor blood/oxygen supply to baby, ketoacidosis, neonatal hypoglycemia, risk neonatal RDS, macrosomia

66 macrosomia

67 Maternal heart disease
Rheumatic heart disease Streptococcus infection scarring Congenital heart defects Cardiac work increased Mitral valve prolapse May or may not have symptoms Peripartum cardiomyopathy Uncommon, seen in late pregnancy or early postpartum S/S similar to CHF

68 Maternal heart disease
Hypertensive heart disease Rise in obesity in pregnant population Cardiac system unable to adjust to pregnancy: edema, hypertension, cyanosis, tachycardia, irregular rhythms, chest pain, dyspnea, fatigue, decreased cardiac output, pulmonary edema, may hear abnormal lung sounds

69 Maternal phenylketonuria
PKU: a genetic disease in which phenylalanine cannot be broken down. Recessive inherited disorder Phenylalanine can build up in brain and nervous system -> delayed development, neuromuscular problems, small head size “musty” odor noted on skin, breath, urine if untreated Treatment involves strict diet High maternal levels can cause fetal defects

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