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MATERNAL CHILD HEALTH NURSING Module 3. objectives  Discuss pregnancy and fetal well-being  Discuss pregnancy complications.

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Presentation on theme: "MATERNAL CHILD HEALTH NURSING Module 3. objectives  Discuss pregnancy and fetal well-being  Discuss pregnancy complications."— Presentation transcript:


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 2 nd, 3 rd 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 3 rd 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  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 16-18 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  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: 37-41 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  Genetic test of placental tissue  Done at 8-12 weeks to avoid fetal injury  Amniocentesis  Done around 16 th 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 32 nd week

32 Screening tests  MRI  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 120-160 beats/minute  Temporary increases/decreases normal with fetal activity  Labs  Blood: anemia, infection, etc  Urine: infection, glucose/protein spilling  Fetal position  As baby nears 37 th 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  Discomforts:  Cause  Interventions  Client education  Warning signs  Cause  Interventions  Client education

38 Discomforts of pregnancy  FON p 792 Table 25-4  When evaluating complaints, consider stage of pregnancy, history, related activities  Shortness of breath: 1 st trimester vs 3 rd  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  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  3 rd trimester changes  Non-contact activities  Changes in rest and sleep patterns

43 Pregnancy: self care  Nutrition  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  1 st trimester: detect chromosomal problems  3 rd trimester: fetal health, maturity  Chorionic villi sampling  1 st 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  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 (2 nd trimester) and 1 lb/week (3 rd 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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