Maternal Child Health Nursing

1. Maternal Child Health Nursing Module 3

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 2nd, 3rd 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 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

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 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

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 37th 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: 1st trimester vs 3rd • 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 • 3rd 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