Maternal-Child Health Nursing

1. Maternal-Child Health Nursing Module 2

2. objectives • Discuss contraception, prenatal education, sexually transmitted diseases and fetal development

3. Contraception and birth control • Natural methods • Barrier Methods – sponge, condom, diaphragm • Hormonal methods • The Pill, shot, ring, patch • “Morning-after” pill • Male contraceptive pill? • Mifepristone (RU486) • sterilization

4. Natural and barrier methods • Rhythm, abstinence, lactational amenorrhea method (LAM) • Barrier: sponge, condom (male and female), diaphragm

5. Hormonal Birth Control • Oral hormones: the pill • Combination pill or “mini-pill” • Injection: depot medroxyprogesterone acetate (DMPA) • Contraceptive patch: Ortho-Evra • Vaginal ring: NuvaRing • Contraceptive implants: Norplant, Implanon

6. What is RU486? • RU-486, or mifepristone, is an artificial steroid that blocks progesterone, a hormone needed to continue a pregnancy. • Note: An RU-486 abortion involves two drugsWhen taken alone, RU-486 causes a complete abortion only about 60% of the time. A second drug, a prostaglandin, is given 48 hours later to increase its effectiveness. The prostaglandin causes uterine contractions to help expel the embryo.

7. Contraceptives

8. Sterilization • Tubal ligation • Permanent means to prevent meeting of egg/sperm • Crushing, ligating, clipping, plugging fallopian tubes • Nearly 100% effective when properly done • Hysterectomy • 100% effective • Vasectomy • Ligation/resection of ductus deferens • 99% effective

9. Intrauterine device (IUD) • Hormonal IUD: flexible plastic, introduces progestin into uterus. 99% effective • Copper T IUD: copper device introduced into uterus. 99% effective

10. STDs: Chlamydia • Tetracycline; doxycycline; azithromycin; erythromycin • TREAT ALL SEXUAL CONTACTS • Nursing interventions • Address emotional responses to STD’s • Focus on patient education and prevention

11. STDs: Cytomegalovirus • A herpes virus capable of being silent in the body for a long time • Transmitted through saliva, semen, blood, cervical and vaginal secretions, urine, and breast milk • Very common, of major concern if pregnant at first infection or in presence of immune weakness

12. STDs: Candidiasis • Not always an STD • Candidiasis • Clinical manifestations • Mouth: edema; white patches • Nails: edematous, darkened, erythmatous nail base; purulent exudate • Vaginal: cheesy, tenacious white discharge; pruritus; inflammation of the vagina • Penis: purulent exudate • Systemic: chills; fever; general malaise

13. Candidiasis: infant diaper rash

14. STDs: Genital herpes • Genital herpes • No cure; treat symptoms • Acyclovir (zovirax) and other antiviral agents • Sitz baths • Local anesthetic; analgesics • Keep lesions clean and dry • GOOD hand washing • No sexual contact while lesions are present • Encourage use of condoms

15. STDs: Gonorrhea • N. gonorrhoeae • One of most commonly reported communicable disease in the U.S. • Estimated 2 million unreported cases each year • Women may be asymptomatic

16. STDs: Hepatitis B • Transmitted via blood, sexual secretions and breast milk, contaminated needles, IV drug use, dialysis • s/s: may be asymptomatic; may include malaise, myalgia, photophobia, headaches, chills, lassitude, pruritis, hepatomegaly, enlarged lymph nodes, weight loss, rhinitis, jaundice, dark urine, clay-colored stools.

17. STDs: Human papilloma virus • More than 100 types, 40 of which affect genital area • Causes warts. Some types can cause cervical cancer (Types 16 and 18) • Oral lesions may be caused by oral-sexual contact • May be transferred from mom to infant during delivery

18. STDs: Syphilis • Treponema pallidum organism • Organism thrives in warm parts of the body • Can be destroyed by soap and water • Penetrates skin and mucous membranes of the genital organs, rectum, and mouth • Transmission occurs primarily with sexual contact

19. STDs: Trichomoniasis • T. vaginalis protozoan • Affects 15% of sexually active women and 10% of sexually active men • Incubation period is 4-28 days • Usually sexually transmitted • May also be transmitted by dirty douche nozzles, douche containers, or moist washcloths • Infected mother may transmit to newborn during birth • Thrives when vaginal pH is more alkaline than normal

20. STDs: HIV/AIDs • Human immunodeficiency virus/autoimmune disease • It may take years for HIV to cause AIDs • May be transmitted by sexual fluids, blood, pregnancy, childbirth, breastfeeding • s/s: early “flu-like”, including fever, h/a, sore throat, rash, swollen lymph glands

21. HIV/AIDs: progressive stages • Relative clinical latency: • Vigorous immune response • Lower viral load • CD4 counts normal or slightly low • CD8 counts comparatively higher • May be symptom-free 10 or more years • About 5% total HIV cases

22. HIV/AIDs: progressive stages • Rapid progressing: • 5%-10% HIV cases • May progress to AIDs diagnosis in two to three years • HIV antibodies low or absent • Impaired CD8 cells • High viral load throughout infection

23. Early infection: AIDS • Pattern of few or no symptoms • Symptoms may not point to HIV infection • Risky behaviors may continue • Individual seemingly healthy

24. HIV/AIDs • Later s/s (possibly years later): Swollen lymph nodes (often a first sign), diarrhea, weight loss, fever, cough and shortness of breath • AIDs usually progresses from untreated HIV in about 10 years. HIV attacks CD-4 immune cells. Diagnosis depends on <200 count in presence of certain illness • Signs and symptoms of AIDS are often of opportunistic illnesses such as tuberculosis.

25. Diagnostic tests: STDs Blood: • Enzyme-linked immunosorbent assay (ELISA) • Western blot • VDRL • RPR • Fluorescent treponemal antibody absorption • Reiter test Culture: • tissue • Discharge

26. Prenatal/preconception care and education

27. Education! • Prenatal care means preconception education • Nurses need to be aware of changes in the ways pregnancy and childbirth are considered • There are many approaches to childbirth that women can consider • It’s important for nurses to be nonjudgmental and knowledgeable in order to maximize education

28. Context and introduction • History of childbirth • Childbirth education and training • NAACOG • AWHONN

29. History of childbirth • Greeks/Romans • Medieval • Early modern • Current

30. Childbirth education and training • 1920: Dr. Joseph DeLee • Childbirth as disease requiring routine interventions • 1930s: Dr. Grantly Dick-Reed • Natural Childbirth • 1950s: Dr. Robert Bradley • Husband-coached childbirth • 1950s: Dr. Ferdinand Lamaze • Breathing, relaxation

31. Professional organizations • NAACOG • 1969 • Part of ACOG • AWHONN • Professional organization of nurses • Benchmark standards for nursing practice in women’s health, obstetric and neonatal care

32. Preconception education and care • Immunizations and disease states • Medications and herbs • Smoking, alcohol, illegal drugs • Genetic risk factors

33. Immunizations and disease status • Rubella immunity • HIV antibody test • Gonorrhea, Chlamydia, syphilis • Pap smear • Hep B screen • Varicella zoster screen • TORCH panel

34. Medications and herbs

35. Medications and herbs • Medicines that can cause bleeding (aspirin), affect prostaglandins (ibuprofen), are based in alcohol (some herbal preparations) or are known to cause birth defects (Accutane) are just some of the medicines unsafe for pregnancy. • Some herbs are used by physicians, midwives and herbalists and have a history of use

36. Smoking, alcohol, illicit drugs • Nicotine can cause low birth weight • Alcohol can cause fetal alcohol syndrome • Drug use can cause withdrawal, prematurity, low birth weight, pregnancy complications

37. Fetal alcohol syndrome in children

38. Genetic risk factors • Personal and family medical histories of both parents • Genetic counselor can educate parents about statistical possibility, risks and treatments

39. Pregnancy

40. Fertilization • Sperm in semen travel through cervical mucus, through uterus and up into ampulla of fallopian tubes • The first sperm to meet a mature ovum wins! • Fusion of sperm with ovum also called conception – takes about 24 hours • Zygote: fertilized egg: 44 autosomes and 2 sex chromosomes

41. implantation • Over 3-4 days, zygote moves to uterus • On the way, zygote undergoing mitosis • Morula -> blastocyst • Blastocyst secretes enzymes that prepare a spot – usually on the anterior or posterior surface of the fundus – to implant • Implantation depends on an enriched endometrium

42. Implantation • Primary villi • Pre-placenta • Use maternal blood vessels for nutrition, oxygen • 2-8 weeks after fertilization • First stages of chorionic villi (early placenta) grow • HCG -> progesterone/estrogen • Primary villi also make protein and glucose for about 12 weeks until fetus can make his own • Turn into fetal portion of placenta

43. Amniotic fluid • Contained in amniotic sac, which is part of the placenta • Volume maintained by fetal urine later in pregnancy • Protects from mechanical injury (shock absorber), helps regulate fetal temperature, allows growing room for fetal development • 30 mL at 10 weeks -> 1 liter by delivery

44. Amniotic fluid • Contains alpha fetoprotein (AFP), urea, uric acid, creatinine, bilirubin, lecithin, sphingomyelin, fructose, fat, leukocytes, proteins, epithelial cells, enzymes, lanugo in changing levels that reflect fetal development • Physical support, taste/smell development, kidney development, may play role in breastfeeding • Amniocentesis

45. Placenta • Filter between maternal and fetal circulation • Oxygen, nutrients, wastes • About 1 pound at delivery • Fetal side smooth, shiny, produces fluid sac • Maternal side rough, red • After week 8, placenta secretes HCG, estrogen, progesterone to maintain pregnancy

46. Umbilical cord • Joins embryo to placenta • Wharton’s jelly • Two arteries and one vein • Arteries carry oxygen-poor blood from fetus to placenta • Vein carries oxygen-rich blood from placenta to fetus • No pain receptors

47. Placenta and umbilical cord • Transport: • Oxygen, nutrients from maternal blood filter through placenta without mixing maternal and fetal blood supplies • Wastes from fetal blood filter back through placenta for maternal disposal • Filtration occurs through diffusion and active transport

48. Placental barrier prevents mixing of maternal and fetal blood

49. Placenta and umbilical cord • Endocrine: • HCG, estrogen and progesterone secretion by chorionic villi (fetal side of placenta) • Metabolism: • Nutrients from mom pass through placenta to fetus • Wastes from fetal metabolism

50. Fetal development • Foundations of Nursing pp 774-783 • Fetal development charts provide ranges of time for normal stages