Maternal & Newborn Nursing

1. Maternal & Newborn Nursing Unit 2

2. Presumptive Signs Amenorrhea: no menses Nausea: 4 – 12th week Breast changes Urinary frequency ------------------------------------------------------------ Quickening: 1st movements felt; 16-20 wks. Fatigue & drowsiness Pigmentation Abdomen = lineanigra: dark line from umbilicus to symphysis Face = chloasma: blotchy, suntanned mask

3. Probable Signs Abdomen enlargement Chadwick sign Bluish / purplish discoloration to vulva & vagina by ↑ blood supply 4th week Goodell’s sign Softening of cervix Hegar’s sign Softening of lower uterine segment 6th week

4. Probable Signs Ballottement Rebounding of fetus against Dr.’s fingers after made it move 4-5th month Braxton Hicks contractions Uterine contractions occurring @ 5-10 minute intervals throughout pregnancy Usually not noticed until end of pregnancy Fetal outline Abdominal striae Pregnancy tests Based on HCG; (+) 10 days after missed period

5. Positive Signs Fetal heartbeat 10 weeks by doppler Fetal movements After 5th month while in supine position Ultrasound As early as 4th week; very accurate after 3rd month

6. Expected Date of Delivery Count backwards 3 months from 1st day of last menstrual period Add 7 days Change year as needed

7. Prenatal Assessment - History • Obstetric • Menstrual • Contraceptive • Medical & surgical • Family history • Woman’s & partner’s health • Psychosocial

8. Prenatal Visits Conception – 28 weeks Every 4 weeks 29 – 36 weeks Every 2 - 3 weeks 37 weeks to birth Weekly

9. Prenatal Assessments - Physicals Review known risk factors & assess new VS same arm & same position Weight UA for protein, glucose, & ketones Glucose screening @ 24-28 weeks Fundal height Leopold’s maneuvers: assess presentation & position of fetus Fetal heart rate: 120 – 160 bpm Electronic doppler by 10 weeks Review nutrition Assess discomforts or problems since last visit

10. Amniocentesis Transabdominal needle aspiration of 10-20mL amniotic fld. for lab analysis Prep Signed consent form Void prior to test Purposes Determine fetal age & maturity Determine Alpha-Fetoprotein (AFP) levels Measure estriol levels & fetal thyroid hormone

11. Post Amniocentesis Monitor FHR & maternal VS q 15 Position on L. side to counteract supine hypotension Instruct to call MD if Leakage of serous vaginal fld. Fetal hyperactivity or unusual fetal lethargy

12. Ultrasound High frequency sound waves to detect FHR, placental location or body parts Purposes Measure size of internal structures Identify pregnancy Detection Fetal maturity Prep Drink fluids Do NOT empty bladder prior

13. Non-stress Test Evaluate FHR accelerations that normally occur to fetal activity Prep L. side semi-fowler’s position Evaluate FHR immediately following activity Monitor Mother’s BP & uterine activity Interpretation + test (good) = FHR ↑ 15 bpm above baseline in response to fetal activity - test (bad) = FHR does not ↑ with fetal movements

14. Oxytocin Challenge Test / Contraction Stress Test Assess FHR to contractions & efficiency of respiratory function of placenta Prep Left side & on monitor Oxytocin infusion or nipple stimulation Interpretation - test = 3 contractions of good quality & duration without late responses of FHR = adequate placenta + test = late responses of FHR = placental insufficiency

15. Cardiac & Respiratory Changes Blood vol. ↑ 45% BP remains about same as pre-pregnancy but P & R ↑ Heart & lungs gradually displaced upward

16. Digestive System Changes Stomach & intestines displaced upward ↓ tone & motility of tract ↓ HCl acid & pepsin secretions Digestive process slows

17. Endocrine Changes Glands ↑ in size & activity Metabolism rate ↑

18. Musculoskeletal System

19. Integumentary Changes

20. Reproductive Changes Breast blood vessels & secreting glands enlarge Uterus ↑ in size, cervix softens Vaginal mucosa thickens Leukorrhea - ↑ vaginal discharge

21. Psychosocial Changes 1st trimester Self-centered & concerned with own adjustment to idea of pregnancy Have feelings of ambivalence 2nd trimester More tranquil, @ ease Reality now recognized, come to accept pregnant state Third trimester Increased vulnerability & dependence Labile mood

22. Promoting Health - Nutrition Nutrient intake = needs of mother & fetus ↑ caloric intake by 300 calories ↑ Vitamin A, C, D & folic acid Wt. reduction programs discouraged Wt. gain up to 4.4 lbs for 1st trimester & 1 lb/wk Normal weight = 25-35 lbs. Overweight = 11-25 lbs. Underweight = 28-40 lbs Obese = 11-20 lbs. PROTEIN, CALCIUM, IRON, FOLIC ACID

23. Promoting Health - Alcohol • Chronic alcoholism • Fetal malformation • ↑ prenatal mortality rate • Pre & postnatal growth retardation • Fetal Alcohol Syndrome • Low IQ’s • Impaired fine & gross motor function

24. Promoting Health - Medication • Take only medications prescribed by a physician who is aware pregnancy

25. Morning Sickness • Prevention • Avoid empty or overloaded stomach • Avoid offending odors • Avoid foods hard to digest • Maintain good posture • Stop or ↓ smoking • Treatment • Carbohydrates upon awakening • Remain in bed until feeling subsides • Alternate dry CHO 1 hr. with fluids • 5-6 small feedings a day • Avoid fried, odorous, spicy, greasy, or gas forming foods • Consult MD if severe vomiting occurs

26. Heartburn / Acid Indigestion • Prevention • Avoid gas forming or fatty foods • Small frequent meals • Maintain good posture • Treatment • Take only antacid prescribed by MD • NO baking soda or Alka-Seltzer = ↑ Na • Hot tea, sips of milk, or chew gum for temp. relief

27. Constipation • Prevention • Drink 8 glasses water/day; roughage • Moderate exercise • Sit on toilet with feet supported on footstool; maintain regular BM schedule • Relaxation techniques & deep breathing • Treatment • Same as prevention measures • Not take stool softeners, laxatives or other drugs or enemas without consulting MD 1st • Never ingest mineral oil = inhibits fat-soluble vitamin absorption

28. Hemorrhoids • Prevention • Chew solid foods slowly & thoroughly • Avoid gas producing foods, fatty foods, large meals • Treatment • Encourage exercise • Eat appropriate foods • Promote regular bowel habits

29. Faintness / Orthostatic Hypotension • Prevention • Moderate exercise, deep breathing, vigorous leg exercises • Avoid sudden changes in position • Avoid warm, crowded areas • Eat 5-6 small meals / day • Treatment • Sit down as needed

30. Supine Hypotension • Side lying position or semi sitting position with knees slightly flexed

31. Ankle Edema • Prevention • Use good posture; moderate exercise • Avoid prolonged standing or sitting • Avoid constrictive clothing • Maintain ample fld. intake for “natural” diuretic effect • Treatment • See MD if generalized edema develops • Support stockings before arising • Rest periodically with legs & hips ↑

32. Varicose Veins • Prevention • Avoid obesity • Avoid lengthy standing or sitting • Avoid constrictive clothing • Avoid constipation & bearing down • Moderate exercise • Treatment • Rest with legs & hips elevated • Support stockings • Warm sitz baths & local astringent compresses

33. Shortness of Breath / Dyspnea • Prevention • Avoid anemia • Treatment • Good posture • Sleep with extra pillows • Avoid overloading stomach • Stop or ↓ smoking

34. Leg Cramps • Prevention • Avoid pointing toes when stretching • Avoid fatigue & cold legs • Maintain adequate Ca⁺ ⁺ intake • Treatment • Stand up & lean forward on affected leg • Extend knee & dorsiflex foot • Take oral supplements TID ac

35. Joint Pain, Backache, Pelvic Pressure • Prevention • Maternity girdle • Good posture & body mechanics • Bend @ knees not hips or waist • Avoid fatigue; relaxation • Wear shoes with wide heels • Firm Mattress • Treatment • Back muscle exercises; pelvic rock • Local heat & back rubs • Rest

36. Urinary Frequency & Urgency • Prevention and Treatment • Kegel exercises • Limit fld. intake before bedtime

37. Pigmentation • Prevention • Stay out of sun • Treatment • Reassurance

38. Breast Changes • Prevention • Not ! • Treatment • Supportive maternity bra with absorbent pads • Wash with warm H₂O & keep dry

39. Fatigue • Prevention • NOT ! • Treatment • Well balanced diet • Rest

40. Insomnia • Prevention • Relaxation techniques • Treatment • Back massages • Support body with pillows • Warm milk or warm shower before HS

41. Abdominal Discomfort • Prevention • NOT ! • Treatment • Rest, relaxation • Good posture; maternity girdle • If pain present, refer to MD • If term, r/o labor

42. Braxton Hicks Contractions • Prevention • NOT ! • Treatment • Encourage to seek & receive reassurance these are necessary • Rest; change position • Practice breathing techniques • Refer to MD if regular & firm

43. Psychological Adaptations

44. Hyperemesis Gravidarum • Exaggerated nausea & vomiting persisting past 1st trimester • Hormonal changes, emotional factors • Signs / Symptoms • Dehydration • Vitamin deficiency • Fld. & electrolyte balance • Hospitalized – IV fluids • Resume oral fluids gradually; high carbs • Other interventions for n/v c/o’s • Develop coping abilities

45. Abortion Spontaneous Threatened Bleeding occurring with or without cramps or backache Bedrest Pad count • Termination of pregnancy before age of viability without mechanical or medical interference

46. Abortion Inevitable Incomplete Parts of conception products retained D & C • Cannot be stopped • D & C

47. Abortion Recurrent / Habitual Missed Fetus died prior to 20 wks. but products remain in uterus Ultrasound & fetal monitoring Oxytocin induction Fibrinogen levels weekly • Spontaneous abortion in 2 or more successive pregnancies • D & C • R/O uterine causes with a hysterogram & treat other possible causes • Cervix suturing

48. Abortion Therapeutic Elective Intentional for other reasons • Termination of pregnancy before fetal viability for safeguarding the mother’s health

49. Ectopic Pregnancy • Any gestation located outside the uterine cavity • Contributing factors • Endometriosis • Tubal surgery • Pelvic inflammatory disease (PID) • Salpingitis • Signs / Symptoms of Tubal Rupture • Sudden, severe, unilateral pain but later generalized pain radiate to shoulder/neck • N & V, faintness; s/s shock

50. Ectopic Pregnancy:Interventions • Prevent / treat shock • VS • Fluid volume management • Pain management • Salpingectomy • Supportive care