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

MATERNAL CHILD HEALTH NURSING

Module 3

objectives

Discuss pregnancy and fetal well-being Discuss pregnancy complications

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”

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

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

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

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

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

Pregnancy: gastrointestinal

Peristalsis slows Gas, constipation, abdominal distension and discomfort

Hemorrhoids from constipation, pressureIron supplements

May have higher cholesterol, cholelithiasis

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

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

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)

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

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

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)

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

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

Factors: psychological response Body image Financial situation Cultural expectations

Status, work Emotional security Support from significant others

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

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

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

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

Prenatal care: initial visit

Fundal heightFrom weeks 18-

30, the height of the fundus in centimeters about equal to weeks’ gestation

Requires skill and experience for accuracy

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

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

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

Descriptive terms

Induced abortion: intentional loss of pregnancytherapeutic: to preserve health of

motherElective: reasons other than health of

mother (fetal abnormality, social reasons)

Gravida: pregnancy Nulligravida: never been pregnant Multigravida: pregnant more than once

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

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

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

Screening tests

Chorionic villus sampling 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

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 resultsFetal breathing movementsFetal muscle toneFetal movementsAmniotic fluid volume

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

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 37th week of pregnancy, usually turns

head down Head-down position best for vaginal birth Leopold’s maneuvers

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

Leopold’s maneuvers

Discomforts vs warning signs Discomforts:

Cause Interventions Client education

Warning signs Cause Interventions Client education

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

Warning signs

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

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

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

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

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)

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

Pregnancy: self care

Clothing Employment Travel Dental care Sexual activity

Anticipatory guidance

Environmental hazards Discomforts Warning signs Nutrition Medications

Pregnancy categories

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

Complications of pregnancy

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

macrosomia

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

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

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