1. Maternal child health nursing Module 4

2. Objectives Discuss infection in pregnancy, Rh and ABO incompatibilities, multiples pregnancies, preterm, true and false labors discuss substance abuse in pregnancy Discuss FDA drug categories

3. Pregnancy: Infections TORCH group – Toxoplasmosis – Other – Rubella – Cytomegalovirus – Herpes genitalis (Herpes Simplex Virus Type 2) – FON p 903 box 28-5 Congenital Rubella Syndrome with rash

4. HIV/AIDs Review: – Human immunodeficiency virus emerged as one of most significant diseases of 20 th century – Acquired immune deficiency syndrome results from HIV -> profound depression of immune system – s/s may present differently in women than in men Common presentation of chronic vaginitis, candidiasis Transmission precautions: mother, infant, care providers

5. A word about standard precautions Standard precautions in healthcare were developed to their present form in response to increasing awareness of blood- and body-fluid-borne illnesses

6. HIV/AIDs Human immunodeficiency virus Causative organism responsible for AIDs Severely depressed immune system Transmitted through body fluids Chronic vaginitis and candidiasis are common presenting problems in women Difficult to determine obstetric risk

7. HIV/AIDs Prevent transmission from mother to child during birth and postpartum – Avoid breaking skin barriers – Delivery within 4 hours of ROM – Breastfeeding not recommended where clean formula available HIV can cause microcephaly and facial deformities in fetus, as well as infecting fetus with virus Later signs of infant infection may include failure to thrive, recurrent infection, interstitial pneumonia, neurological problems

8. Other infections STDs Vaginal Urinary tract

9. Nursing care: infections Anti-infective: is Mom responding well? Is she having side effects? Hydration: is mom drinking enough fluids? Elimination: constipated? Diarrhea? Urination: is Mom’s urine dark, concentrated? Nutrition: is Mom getting the right nutrition to help her get well? Immune function: is she resting? Anxious? Showing signs of other infection? Exercising?

10. Rh incompatibility Rh negative mom, Rh positive fetus First vs subsequent pregnancies – Antibodies, antigens from first pregnancy – Attack second pregnancy: erythroblastosis fetalis Hyperbilirubinemia – Can cause RBCs to break down too quickly in newborn – Kernicterus is buildup of bilirubin in CNS

11. Rh incompatibility

12. Coomb’s test – Direct: tests infant’s blood for antibody-coated RBCs – Indirect: tests mother’s blood for number of antibodies RhoGAM – IM injection of anti-Rh gamma globulin – Given to Mom at 28 weeks and at 72 hours postpartum to prevent antibody development – Also given if Rh-negative mom has abortion, ectopic pregnancy or amniocentesis

13. Rh incompatibility Phototherapies – Fluorescent lights make bilirubin easier to excrete – May be in form of blanket (Wallaby fiberoptic) teaching – How disease works – RhoGAM: how it works, when to have it, who should have it, keep records with Mom – Phototherapies: eye protection under lamps, skin exposure

14. Fluorescent light therapy

15. ABO incompatibility Most often: Type O mother leaks antibodies to type A, B or AB baby Rare Can happen with first pregnancy May also cause erythroblastosis fetalis Treatment similar as for Rh incompatibility

16. Multiples pregnancies

17. multiples Twins (33.1 per 1,000 live births) – Monozygotic: fertilized egg splits at embryonic stage -> identical twins – Dizygotic: two eggs fertilized -> fraternal twins Triplets or higher order births (137.6: 100,000 live births) Quadruplets or greater number usually result from fertility drugs Prematurity a risk for multiple births

18. multiples Risks: abortion, maternal anemia, PIH, placenta previa, abruptio placentae, hydramnios Resources: parents of multiples groups, financial resources, resources for baby supplies, may need referrals to lactation consultant Education: self-care, time management, needs unique to pre-term babies

19. multiples Increase with certain fertility treatments Fertility treatments may be given to older mother – Stressed resources, energy, health – May have had more complicated pregnancy due to advanced maternal age – Lessened support: older grandparents, peers raising older children – Parents may have more education and earning power

20. Substance abuse in pregnancy

21. Substance abuse includes both legal (nicotine, alcohol) and illegal (cocaine, marijuana) drugs Prescription drugs and other medications can also cross the placental barrier and affect the fetus Alcohol, tobacco and marijuana most commonly used during pregnancy

22. Substance abuse in pregnancy Cocaine: constricts blood vessels – Detached placenta – Intracranial bleeding Tobacco – Low birth weight – Increased risk of SIDS Narcotics – Withdrawal symptoms – Preterm labor, spontaneous abortion

23. Substance abuse in pregnancy Alcohol – No safe amount for pregnancy has been determined – Results: abortion, fetal demise, IUGR, fetal alcohol syndrome, fetal alcohol effects – FAS: facial/cranial abnormalities, delayed development, mental retardation, short attention span

24. Substance abuse in pregnancy Sedatives (barbiturates, tranquilizers) – Delayed lung maturity – Neonatal abstinence syndrome Amphetamines (speed, crystal, ice) – Placental abruption – Cleft palate Marijuana – Often used with other drugs – IUGR

25. Substance abuse in pregnancy Caffeine: stimulates fetus

26. Nursing care: substance abuse Safe withdrawal Nonjudgmental attitude Prevention of injury – Prevent shaken baby syndrome Assessment (mother and baby): vital signs, changes in baseline, s/s withdrawal Education of infant needs and provide social support

27. Neonatal abstinence syndrome Fetus exposed to addictive drugs in utero and born dependent on them When baby is born, supply is abruptly cut off May cause long-term developmental and neurological problems S/S: tremors, hyperirritability, wakefulness, diarrhea, poor feeding, sneezing, yawning Treatment: IV fluids, small amounts of similar substances to control symptoms Nursing: minimize stimuli, swaddling, seizure precautions

28. FDA drug categories Assigns A, B, C, D or X designation to drugs to differentiate risk Proposal has been made to update drug information to more accurately reflect risk Note that drug categories do not necessarily reflect ascending risk

29. FDA drug categories

30. Preterm labor

31. Preterm: 0-37 weeks Late preterm: 34-37 weeks May be prompted by known or unknown cause – Maternal infection or dehydration, fetal disease – Terbutaline SQ, magnesium sulfate IV titration Non-Braxton Hicks contractions, cervical dilation, s/s true labor

32. preterm labor Terbutaline/Brethine – SQ, PO – Acts on smooth muscle and inhibits uterine muscle activity – FDA warns against using injected terbutaline longer than 48-72 to stop preterm labor Maternal heart problems

33. Nursing care: preterm labor Encourage hydration Monitor FHR, status Note time, color, amount, odor of any amniotic fluid Monitor maternal v/s Treat underlying cause

34. True and false labor Contractions – Regular pattern v irregular – Increase in intensity, duration, frequency over period of hours or days (not weeks) v stop with ambulation or position change – Start in lower back, travel to lower abdomen v fundus or back – Do not stop after interventions v decrease with interventions

35. True and false labor Cervical softening, effacement, dilation v possible softening without effacement or dilation Fetal descent into pelvis v no significant change in fetal position Educate regarding physiological benefit to fetus when pregnancy allowed to continue to 40 weeks