NURS 3031 Childbearing Family Theory Maternal Nutrition PDF

NURS 3031 - Childbearing Family Theory Chapter 12: Maternal Nutrition Maternal and Fetal Nutrition · determinants of health -> impact on dietary intake · good nutrition before and during pregnancy is an important preventative measure · a mother’s nutrition a...

NURS 3031 - Childbearing Family Theory Chapter 12: Maternal Nutrition Maternal and Fetal Nutrition · determinants of health -> impact on dietary intake · good nutrition before and during pregnancy is an important preventative measure · a mother’s nutrition and lifestyle affect the long-term health of her children · inadequate nutrition can lead to an increase in low birth weight (LBW) infants (2500g or less) preterm infants Nutrient Needs Preconception · the first trimester is crucial for embryonic and fetal organ development · a healthy diet before conception ensures that adequate nutrients are available for the developing fetus Key Component of Nutrition: 1. Nutrition Assessment – BMI -> appropriate weight for height 2. Diagnosis for risk factors such as diabetes, phenylketonuria and obesity that require nutrition intervention 3. Intervention based on dietary requirements and plan 4. referrals to dietician if necessary · folic acid intake is important in the periconceptional period o neural tube defects (NTD) are more common in infants of women with poor folic acid intake o Low risk: 0.4mg daily for a least 2-3 months before pregnancy, throughout pregnancy, and during the postpartum period of breastfeeding o moderate risk (diabetes, epilepsy, obesity, or first or second-degree relative with a history of NTDs: 1.0mg daily for the 3 months before pregnancy and during the first trimester -> decrease dose to 0.4mg after the first trimester o increased or high risk for NTD (partner or self who has had NTD or a previous pregnancy with NTD): 4mg/day prior to conception and through the first-trimester of pregnancy after which time can decrease intake of 0.4 to 1.0mg daily foods with folic acid should be encouraged o low birth weight -> thermoregulation  the amount of folic acid required depends on the risk for NTDs in the patient and partner Nutrient Needs During Pregnancy · Calories are the same as non-infant person · 2nd trimester adds about 340 kcal extra than pre-pregnancy needs -> 3rd trimester 450 kcal more than pre-pregnancy needs (adjustments made for multiple gestation) · Energy needs need to be met by fat, carbs and protein Protein · fetal growth, enlarged uterus& its supporting structures, mammary glands and placenta (25g extra a day) · increases maternal circulating blood volume -> maintains colloidal osmotic pressure · helps with formation of amniotic fluid · high protein supplements are not recommended because of the potentially harmful effects on fetus Fluids · About 2 1/2 L a day · limit intake of fruit juice -> high cal · Dehydration may increase risk of: o Decreased amniotic fluid o Renal insufficiency o Braxton hicks contractions o hyperemesis gravidarum o preterm labour Omega 3s o important for growth and development (neuro** improves vision & func) o Fish (5oz 1/week) - low in mercury o Vitamins and minerals o lower risk of heart disease and preterm birth Iron · needed for the transfer of adequate iron to the fetus and to permit the expansion of maternal RBC mass o Physiological anemia (preterm and LBW) o 30mg per day -> increase does if iron deficiency anemia is present (60-120mg) o Always take vitamin C to increase absorption Calcium (1000mg/day 19 and older or 1300 if younger than 19) o Side effect: constipation o Taken with vitamin D to increase absorption(2000 IU/day) Vitamin D o deficiency of vitamin D may lead to newborn hypoglycemia, tetany, hypoplasia of tooth enamel  o Reduces risk of miscarriage o If someone is having frequent miscarriages, you would test for vitamin D Weight Gain: BMI = Weight/Height BMI · Normal: 18.5-24.9 · underweight patients (< 18.5) are more likely to have preterm birth, SGA, and spontaneous miscarriage, intrauterine growth resuscitation · Overweight patients (25-29.9) multiple gestation, edema, gestational hypertension, overeating · Obesity: macrosomia, fetopelvic disproportion, operative vaginal birth, C-section, postpartum hemorrhage, UTI, birth trauma, wounds, pre-eclampsia, fetal death and gestational diabetes IRON + VITAMIN C, FOLIC ACID +B12, CALCIUM +VD (absorption) Nursing Care Management · Diet history o Eating disorder o Neural tube defects o History of anemia o Diabetes, renal, liver disease, cystic fibrosis or other malabsorptive disorders, seizures, anticonvulsant agents, hypertension, PKU · obstetrical and gynecological effects on nutrition · Health history and use of maternal diet o Pyrosis * o Morning sickness * o constipation* · diet, food allergies, cultural dietary requirements · Physical examination o Weight gain or loss (BMI) o Skin turgor o Cap refill  · Laboratory testing o Anemia o Ferritin o Hemoglobin o CBC · Plan of care and implementation o nutrition care and teaching - Canada's food guide - safe food preparation · sprouts- shouldn’t eat because they carry bacteria (listeria) - medical nutrition therapy - vegetarian diets · decreases iron stores (B12*) · B12 is only found in animal sources so they are often deficient and require supplementation - cultural influence · Coping with nutrition-related discomforts of pregnancy o nausea and vomiting (morning sickness) Hyperemesis graviera – when the patient is unable to keep food and fluids down -> severe and results in hospitalization Nutrient Needs During Lactation Nutrition needs during lactation are similar to those during pregnancy needs for energy (kilocalories), protein, calcium, iodine, zinc, the B vitamins and C are greater than nonpregnant needs increase 0.5-1kg per month from breastfeeding Chapter 13: Pregnancy Risk Factors and Assessment Assessment of Risk Factors · most births are low-risk, but some are categorized as high-risk because of maternal or fetal complications · Identification of risks, with appropriate and timely intervention, prevents morbidity and mortality of mothers and infants · Those with mental health issues or difficulty accessing parental care are at risk o Any practitioner can bring this up and see information on there EBD Ultrasounds IVF GTPAL Obstetrical history o Important for medical history-> what is their risk? Definition and Scope of the Problem · high-risk pregnancy o the life or health of the mother or fetus is jeopardized o for the mother, high-risk status arbitrarily extends through puerperium (approx.6 weeks after childbirth) o maternal complications usually are resolved within 1 month of birth o high-risk diagnosis imposes a situational crisis on the family · Determinant of health as risk factors · Canadian perinatal surveillance system o the CPSS is based on the concept of health surveillance as a systematic, ongoing process that provides timely, relevant information about trends and patterns in the health status of a population and the factors that influence health status o the CPSS is currently reporting on 27 perinatal health indicators · An increase in cortisol is highly linked · Being stressed during COVID-19 increased preterm births (cortisol) Regionalization · quality care to all pregnant women and newborns according to their need · utilization of highly skilled personnel, intensive care facilities Centralization · all mothers and babies are referred to a central hospital for care no matter what their needs are Regionalization: Level of Care Centers · Level 1 o low-risk pregnancies, deliveries and newborns · Level 2, 2A,2B,2C o low to moderate-risk pregnancies and neonatology · Level 3A and 3B: o high to ultra-high-risk pregnancies, deliveries and newborns Definition and Scope of the Problem · Assessment of risk factors o genetic considerations o personal health practice and coping skills o demographic characteristics Maternal Health Problems · 3 major causes of maternal death: o hypertensive disorders o infection o hemorrhage · Factors related to maternal death o age < 20, > 35 years, lack of prenatal care, low education level · Mental health concerns and IPV o Polyhydramnios o Intrauterine growth restriction o Preterm labour o Other causes of neonatal death o Potential fetal compromise Fetal and Neonatal Health Problems · preterm multiple birth rates are the leading cause of neonatal morbidity and mortality · other causes of neonatal death o resp distress syndrome o sudden infant death o effects of maternal complications Antepartum Testing Prenatal Screening First-trimester screening is for fetal aneuploidy and second-trimester ultrasound examination is to detect all fetal anomalies (should be offered to all pregnant pts) First Trimester - ultrasound examination for nuchal translucency combined with Screening assessment of maternal serum biochemical markers (11-14 wks) - nuchal translucency (NT) screening is a measurement of fluid in the nape of the fetal neck to identify possible fetal abnormalities -> fluid collection greater than 3.5mm is highly indicative of genetic disorders or risk for congenital heart defect and a fetal echocardiogram would be recommended in 2nd trimester - Protein-A- A (PAPP-A) & beta- human chorionic gonadotropin used to detect Down syndrome (PAPP-A is lower in DS) Second Trimester Maternal Serum alpha-fetoprotein (MSAFP) Screening · maternal serum levels are used as a screening tool for neural tube defects (NTDs) in pregnancy · detects 80-85% of all open NTDs and open abdominal wall defects early in pregnancy · screening recommended for all pregnant women at 15-20 weeks · compare values to what is normal for that week’s gestation · triple and quad-screening to detect autosomal trisomies (21 Downs and 18 at 16 weeks ) · Not diagnostic just indicates a possibility** · You want to know if the mother wants to keep the baby still · All voluntary · Biomarkers from the neck - greater than 3mm indicate problems · Greater than 3.5mm - genetic heart defect · Second trimester - neural tube defects · Look at blood markers in the mother · Follow up with amniocentesis to make sure it’s a true positive · NIPT - not free*** o If you turn 40 and are going to have a baby o Or you have a baby with an abnormality · Ultrasound o To monitor fetal heartbeat o Positioning o Gender o Limbs - measurements · Amniotic fluid * o Polyhydramnios · Ultrasounds for fetal growth · Mom has really slow or really fast weight gain Non-invasive Cell-Free DNA screening (maternal blood sample) prenatal testing · detection rate of 99% for trisomy’s 21&18 · Although may match diagnostic test results are referred for amniocentesis or chorionic villus sampling to confirm the findings  Ultrasonography · fetal activity and gestational age, abnormal fetal growth curves and placental anatomy in early pregnancy · Patients are required to have a full bladder to push the uterus up in order to get a better image of the fetus · position: small pillow under head and knees Biochemical Assessment · coomb’s test o test Rh incompatibility o detects other antibodies that may place the fetus at risk for incompatibility with maternal antigens o if above 1:8 amino required for the severity of bilirubin in amniotic fluid is indicated to establish the severity of fetal hemolytic anemia · Amniocentesis o performed to obtain amniotic fluid, which contains fetal cells to test for chromosomal problems -> possible after week 14 of pregnancy o under ultrasound, a needle is inserted trans abdominally into the uterus and amniotic fluid is withdrawn o indications: prenatal diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity and rarely a diagnosis of fetal hemolytic disease o Complications: Maternal-> leak of amniotic fluid, bleeding, fetomaternal hemorrhage with possible Rh isoimmunization, infection, labour, placental abruption, accidental damage to intestines or bladder and amniotic fluid embolism Fetal-> death, hemorrhage, infection, direct injury from needle · Chorionic villus sampling (CVS) o technique for genetic studies (commonly used for the advantage of earlier diagnosis and rapid results) o performed between 10-13 weeks of gestation o removal of a small tissue specimen from a fetal portion of the placenta chorionic villi originate in zygote -> tissue reflects the genetic makeup of the fetus o genetic studies o contraindicated if cervical infection is present (e.g. Chlamydia or Herpes) · due to the risk of hemorrhage pregnant Rh negative should receive Rh IVIG to avoid isoimmunization Percutaneous umbilical blood sampling (PUBS) or cordocentesis o insertion of a needle directly into the fetal umbilical vessel under ultrasound guidance o direct access to fetal circulation nd · 2 and third trimesters · determines mutation, fetal anemia, infection and thrombocytopenia  · bleeding is the most common complication · fetal bradycardia can also occur Third Trimester Assessment · fetal movement counting (first and second trimesters) · electronic fetal monitoring o nonstress test (NST) the pregnant patient should have an empty bladder and be seated in a reclining chair (or semi-fowlers) with a slight left tilt to optimize uterine perfusion and avoid supine hypotension recorded with doppler not recommended to stimulate or encourage fetal movement (e.g. glucose) o 6 movements or more in 2 hours tells us that there is fetal wellbeing o A reduction in activity would indicate the baby is not getting enough oxygen o Contact a midwife or go to the hospital o Same thing as before with the external monitor Fetal HR Semi fowler's position Right hip elevated Any uterine activity for 20 minutes · Is it normal? Risk factors or not · Fetal kick counts · Biophysical · Amniotic fluid volume check · NST · Accelerations · Decelerations Comparing to baseline Antenatal Assessment Using Electronic Fetal Monitoring Contraction stress test (CST) procedure nipple stimulated contraction test oxytocin-stimulated contraction test interpretation provides a warning of fetal compromise earlier than NST See how baby handles contractions Will the baby be compromised Poor placental perfusion or not The goal is to make contractions happen 3 contractions each long over 10 minutes  ○ Hyperstimulation is at risk so slowly increasing the rate of oxytocin is recommended Nipple stimulated - massage nipple for two minutes, rest for 5 and then continue doing that until contractions start Oxytocin-induced contractions - very low dose because you don’t want to induce labour (0.5-1 ml unit) increase every 15-30 minutes If normal - negative contraction stress test Late decelerations - positive and needs c-section Don’t do this on patients who have ○ Previous c-section ○ Risk for preterm ○ Rupture of membranes ○ Placenta previa or placenta Bravia Ultrasound for Fetal Well-Being · Biophysical profile (BPP) – movements of baby breathing o score interpretation · Amniotic fluid volume (AFV) o abnormalities in AFV are frequently associated with fetal disorders · Doppler blood flow o study of blood flow noninvasively involving the use of systolic and diastolic flow ratios and resistance o reduces perinatal mortality and unnecessary interventions in IUGR Component Criteria 1. Breathing At least one episode more than 30 seconds Movements 2. Movements At least three body or limb movements 3. Tone An episode of active extension with return to flexion of limb or trunk or opening and closing of the hand 4. Amniotic Fluid At least one cord and limb-free fluid pocket which is 2cm Volume in two measurements at right angles Nursing Role in Antenatal Assessment for Risk · psychological considerations o women undergoing antenatal assessment are anxious  the test may show suspected fetal compromise, deterioration of the maternal condition, or both third-trimester women are concerned about protecting themselves and their fetuses and consider themselves vulnerable Chapter 14: Pregnancy at Risk: Gestational Conditions Chapter 14 Gestational Conditions Disorders that did not exist before pregnancy Puts woman and fetus at risk Hypertension in Pregnancy Women over 40 at highest risk Leading cause of maternal and perinatal morbidity and mortality worldwide Primary causes: ○ Hepatic rupture ○ Placental abruption ○ Eclampsia ○ Seizure ○ Coma Hypertensve Disorder of Pregnancy (HDP) Nonsevere HTN: 140/90 ○ Tx: antihypertensives to reduce risk of severe HTN Severe HTN: 160/110 (obstetrical emergency) Classification Chronic/Pre-existing HTN: ○ present before pregnancy or before 20 weeks gestation ○ Most pregnancies are uncomplicated, often have increased risk poor fetal growth & fetal stillbirth ○ At risk for developing superimposed pre-eclampsia Chronic HTN w/ superimposed pre-eclampsia ○ Defined as: HTN before 20 wks gestation w/ new onset of proteinuria HTN and proteinuria before 20 wks gestation Thrombocytopenia (low platelet count) Elevated liver enzymes  Gestational HTN: ○ develops 20 wks after gestation in absence of proteinuria and w/out changes in blood work ○ Not associated with fetal growth restriction Pre-eclampsia: ○ 140/90 or higher w/ new onset of proteinuria or worsening proteinuria ○ Multisystem, vasospastic disease process of reduced organ perfusion characterized by HTN and proteinuria ○ Pregnancy specific syndrome ○ Symptoms: protein in urine, decreased LOC, medications aren’t working, edematous, oliguria, acute liver and kidney function, seizure, stroke, severe headaches, thrombocytopenia, DIC, hemolysis ○ *Proteinuria: characterized as concentration of 0.03g/L or more* dipstick to test; presence of protein determined by +2 ○ Risk factors: nulliparity, age >40 years, pregnancy w/ assisted reproductive technology, family hx of pre-eclampsia, obesity/gestational diabetes, chronic HTN, renal disease, multifetal gestation, pre-existing medical/genetic conditions, type 1 diabetes mellitus ○ Adverse complications CNS: headache/visual disturbances (increase risk of severe complications) cortical blindness/retinal detachment, GCS wernicke encephalopathy Etio: high levels of estrogen or human chorionic gonadotropin (hCG), reflux, reduced gastric motility, stress/anxiety Manifestations: protracted vomiting, retching, severe dehydration, and wt loss requiring hospitalization ○ Will lose 5% of prepregnancy weight w/ dehydration symptoms: decreased BP, increased HR, poor skin turgor Nursing Care ○ Assessment: frequency/severity of episodes, sleep patterns, other GI symptoms, prepregnancy weight, effective/noneffective interventions, vitals, physical exam, urine dipstick, lab test, psychosocial  ○ Diet: clear, liquid diet, slowly increased w/ small frequent bland meals high in protein or carbs, low in fat Avoid odours, tastes, stuffy rooms, visually stimulating lights, or strong perfumes (triggers) ○ Nonpharmalogical: ginger, wrist acupuncture (Nei Guan pressure point), and mindfulness-based therapy ○ Pharmacological: pyridoxine (vit b6) w/ or w/out doxylamine (diclectin), dimenhydrinate (gravol), diphenhydramine (benadryl), corticosteroids if previous don’t work but can increase risk of facial clefting for fetus *if those medications don’t work Ondsateron (Zofran) is indicated* ○ May need IV if can’t consume orally: give antiemetics, antacids, nutrition supplements; observe for metabolic acidosis, jaundice, hemorrhage, I/O Standardized Assessment Tool Hemorrhagic Disorders Considered medical emergencies 50% due to placenta previa or placental abruption Decreased oxygen carrying capacity Increases risk for hypovolemia, anemia, infection, preterm labor, and preterm birth Fetal risks- anemia, hypoxemia, hypoxia, anoxia, stillbirth Early Pregnancy Bleeding Miscarriage (spontaneous abortion): pregnancy ends before 20 wks gestation or less than 500g Etio: chromosomal abnormalities, endocrine imbalances, immunological factors, systemic disorders, and genetic factors ○ Increased risk if obese and varicella infxn Late miscarriage: between 12 - 20 wks of gestation ○ Results from advances age, chronic infxn, premature dilation, chronic debilitating diseases, inadequate nutrition, and recreational drug use Manifestations: uterine bleeding/cramping, low back pain (ominous sign)  Types and Symptoms: ○ Threatened: mild/moderate spotting and cramping w/ closed cervical os ○ Inevitable/incomplete: moderate-heavy bleeding/cramping w/ open cervical os ○ Inevitable: rupture of membranes/cervical dilation w/ passage of fetus and placenta ○ Incomplete: expulsion of fetus w/ retention of placenta ○ Complete: fetal tissue passed w/ closed cervical os ○ Missed: fetus has died, but products of utero are retained for a few weeks w/ closed cervical os ○ Recurrent: three or more consecutive losses before 20 wks gestation Collaborative Care: assess preg hx, vital signs, pain, bleeding, emotional status, lab test ○ Supportive care ○ Suction for placenta, uterine evacuation (fetal death), intravaginal misoprostol (outpatient)- induces labour, dilation and curettage (D&C) scrape uterine walls and remove uterine content  analgesics/sedatives during procedure, oxytocin after procedure to prevent hemorrhage, antibiotics given PRN, ibuprofen for comfort, blood transfusion for shock/anemia, Rh negative given Rho(D) w/in 48 hrs ○ Psychosocial: grief; complex and unique Explain procedures, possible complications, and future child-bearing implications, how to manage grief, how to manage grief Offer the choice to spend time w/ fetal remains ○ If vitals stable, minimal vaginal bleeding, recovery from anesthesia discharge likely after D&C Need for rest, iron supplementation if significant blood loss, teach normal findings (cramping, bleeding, sexual activity, family planning) Premature Dilation of Cervix Incompetent cervix, cervical insufficiency Cervix dilates w/out cramping; passive and painless dilation of cervix Caused by infection, previous abortions (D&C), damaged or shortened cervix (less than 25mm), common w/ twins Etio: can be acquired or congenital ○ Congenital risk factors: collagen disorders and uterine abnormalities ○ Acquired risk factors: hx of previous cervical trauma (laceration), mechanical dilation, prior cervical surgery  Diagnosis: speculum and digital pelvic examinations and transvaginal ultrasound examination, short labour and recurring loss of pregnancy are characteristics of cervical incompetence Collaborative Care: cervical cerclage (McDonald technique)- suture placed around cervix below the mucosa to constrict the cervix’s internal os ○ Viable for 24 wks ○ Cerclage placed prophylactically (12-14 wks gestation), therapeutically (14-23 wks gestation- singleton pregnancy or hx of preterm birth for short cervix), or rescue procedure (16-23 wks gestation- found to have cervical change; greater than 1 cm dilated or prolapsed membranes) ○ Removed if premature ROM; if not complications, removed at 36 wks ○ Abdominal cerclage indicated if failure of prior transvaginal cerclage, where spontaneous preterm birth occurred before 33 wks C-section necessary ○ Assess pt feelings/understanding, previous reactions to stress/coping, evaluate support systems, for cerclage monitor presence of contractions, PROM and infection ○ Discharge: monitoring at home and follow ups ○ Follow Up: bed rest after cerclage (less pressure on cervix), progesterone therapy, plans for physical activity/intercourse individualized, educate signs of preterm labor, ROM, infxn, and signs for immediate hospitalization (reg. Strong contractions, PROM, severe perineal pressure, urge to push) ○ Unsuccessful management: grief support Ectopic Pregnancy Fertilized ovum implanted outside uterine cavity (majority in fallopian tube); increased in those w/ assisted reproductive therapy Leading cause of infertility; frequent occurrence can cause pelvic inflammatory disease Causes: STI, tubal infxn/damage, tubal sterilization, increased use of assisted reproductive techniques and tubal surgery Surgery to remove embryo/fetus as soon as abdominal pregnancy identified to prevent hemorrhage Fetal deformities caused by oligohydramnios; common concerns ar facial/cranial asymmetry, various joint deformities, limb deficiency, and CNS anomalies Manifestations: abd pain, delayed menses (mild dark brown blood), spotting, shoulder pain (diaphragmatic irritation by blood in peritoneal cavity) if diagnosed after rupture w/ abd pain (manage w/ medications), signs of shock, ecchymotic blueness around umbilicus (Cullen’s sign)  Diagnosis: symptoms of abd pain, vaginal spotting/bleeding, and positive pregnancy test, lab tests, transvaginal ultrasound, internal bleeding (signs: vertigo, should pain, hypotension, tachycardia), palpable mass on examination Medical Management: Methotrexate IM (antimetabolite and folic acid antagonist that destroys rapidly dividing cells) ○ Prevents needs for surgery, safe, cost effective, pt must be hemodynamically stable w/ normal liver and kidney fxn ○ Don’t take analgesic stronger than acetaminophen; can mask symptoms of tubal rupture Surgical management: removal of entire tube (salpingectomy)- if not ruptured ○ BP, pulse, respirations assessed before surgery, blood replacement may be necessary, reop lab tests, ultrasound, Rh antibody if needed Follow up Care: monitor b-hCG levels weekly, resolution time (resolves w/in 2-3 wks), emotional support future fertility discussion, contraception (used for at least 3 menstrual cycles for recovery), early pregnancy awareness, support groups (grief/infertility) Gestational Trophoblastic Disease Hydatidiform Mole (molar pregnancy)- benign, proliferative growth of placental trophoblast Caused by ovular defect or nutritional deficiency High risk for older adults and younger teens Types: Complete mole: results from fertilization of egg w/ lost or inactivated nucleus; grape like clusters found on ultrasound- contains no fetus, placenta, amniotic membranes, or fluid  ○ Partial mole: result of two sperm fertilizing a normal ovum; contain embryonic/fetal parts and amniotic sac Manifestations: complete- dark brown vaginal bleeding, ultrasound finding “snowstorm pattern” of multiple intrauterine masses seen instead of fetus, B-hCG will remain high Medical management: suction curettage offers safe, rapid, and effective evacuating ○ Oxytocic agents/prostaglandins not recommended can increase risk of embolism of trophoblastic tissue Nursing Care: provide info about disease process, consequences, coping w/ pregnancy loss, family encouragement to express feelings, support groups/counselling Late Pregnancy Bleeding Placenta Previa: placenta implants in the lower uterine segment, partially or completely covering cervix; may be diagnosed second trimester Diagnosis: sonography to measure distance from placental edge to the internal cervical os using transvaginal ultrasound Complete: placenta covers entire cervical os Marginal: placental edge is within 2.5cm of internal cervical os Low-lying: when exact relationship to os is unclear or in cases apparent placenta previa in second trimester Risk factors: previous c-section, advanced maternal age, multiparity, smoking, Asian population, male fetus, previous placenta previa, endometrial damage Manifestations: painless, bright red bleeding during 2nd/3rd tri (associated w/ disruption of placental blood vessels), vitals signs normal, decreased urinary output, fundal height higher than expected for gestational age, fetal malpresentation (breech, transverse, etc) At risk for hemorrhage, placental attachment problem, C/S, anemia, infection, preterm birth, stillbirth, malpresentation, fetal anemia, IUGR, fetal anomalies Nursing Care: reduced activity, close observation, bleeding (check pad), fetal surveillance (NST/BPP), lab tests, steroids before 34 wks for fetal lung maturity, pelvic rest (vaginal exams postponed until fetal viability) ○ C-section @ 37wks Immediate c/s if beyond 36wks, excessive bleeding, termination of expectant management (mature fetus, bleeding worsens, labor starts, complicates like chorioamnionitis) Assess BP, HR, LOC, urine output, maternal and fetal status preparing for surgery Emotional support  ○ Can lead to massive blood loss and hypovolemic shock ○ Admission to tertiary perinatal center Placental Abruption The detachment of part or all the placenta from its implantation site Risk Factors: maternal hypertension, cocaine use, blunt external abdominal trauma, smoking, hx of abruption, PROM, inherited/acquired thrombophilias Classifications: Manifestations: sudden onset of intense uterine pain, vaginal bleeding, abd pain, uterine tenderness, contractions, uterine hypertonicity, shock Maternal complications: hypovolemia, coagulopathy, pain, couvelaire uterus (purplish, copper-color uterus w/ lost contractility), shock, DIC, renal failure, infxn Fetal Complications: IUGR, oligohydramnios, preterm birth, hypoxemia, stillbirth ○ Longterm: neurological defects, cerebral palsy, SIDS Diagnostics: Kleihauer-Betke (KB) test: used to detect fetal-to-maternal bleeding, ultrasound to rule out placenta previa Management: observation of bleeding/labour signs, fetal monitoring (FHR, NST, BPP), corticosteroids (fetal lung maturity), Rho(D) immunoglobulin (Rh-neg pt) Nursing Care: close monitoring, education (abruption, tx, outcomes), emotional support, support  Indications for immediate birth: pt condition deteriorates, fetal distress/severe hemorrhage (c/s performed), vaginal if mother is hemodynamically stable ○ May require hysterectomy Cord Insertion and Placental Variations Placenta Accreta: serious complication of placenta previa, defined by trophoblastic invasion beyond the normal endometrial barrier Placenta Increta: invasion extends into the myometrium Placenta Percreta: invasion extends beyond the uterine serosa Risk: massive hemorrhage Management: c/s w/ fundal incision; followed by total abdominal hysterectomy Vasa Previa: fetal vessels lie over cervical os, implanted into fetal membranes instead of placenta ○ Risks: unprotected vessels may rupture or be compressed -> fetal hemorrhage, may need hysterectomy ○ Risk factors: hx of second trimester placenta previa, low-lying placenta, assisted reproduction, and multiple gestations ○ Types: Velamentous insertion of the cord- umbilical vessels branch at the membranes and course onto the placenta Succenturiate Placenta: placenta divides into two or more lobes; fetal vessels run btwn lobes Risk: separate lobes may remain attached during labor, increasing PP hemorrhage DNC to remove Battledore (Marginal) Insertion of Cord: cord inserts at the placenta’s margin rather than centrally ○ Risk: increased fetal hemorrhage, especially after marginal separation of placenta Clotting Disorders in Pregnancy Disseminated Intravascular Coagulation (DIC) Definition: DIC is a pathological condition characterized by excessive clotting, which depletes clotting factors and platelets, leading to widespread bleeding and ischemia. Causes in Pregnancy: ○ Placental abruption (most common trigger). ○ Retained dead fetus syndrome. ○ Amniotic fluid embolism.  ○ Sepsis or HELLP syndrome. Pathophysiology: ○ DIC involves overactivation of the clotting cascade and fibrinolytic system, resulting in microvascular fibrin clots that obstruct circulation. ○ Blood cells are destroyed as they pass through these clots, worsening the depletion of clotting factors. Management: ○ Correct the underlying cause (e.g., treat infections, resolve placental issues). ○ Administer blood products, clotting factors, and fluids to replace losses. ○ Use medications such as vitamin K or fibrinogen as needed. Nursing Interventions: ○ Monitor for signs of bleeding (e.g., petechiae, hematuria, oozing from injection sites). ○ Ensure adequate urine output (≥30 mL/hr) to prevent acute renal failure. ○ Administer oxygen (8–10 L/min) and warm the patient to maintain body temperature. ○ Use continuous fetal monitoring if DIC occurs before delivery. Von Willebrand’s Disease Definition: A hereditary bleeding disorder caused by a deficiency of von Willebrand factor (vWF) and factor VIII, leading to prolonged bleeding times and platelet dysfunction. Symptoms: ○ Heavy menstrual bleeding. ○ Mucosal bleeding. ○ Family history of bleeding disorders. Management: ○ Desmopressin (DDAVP): Increases vWF and factor VIII levels. ○ Plasma concentrates of vWF and factor VIII as needed near delivery. ○ Avoid instrumental deliveries and fetal scalp electrodes to minimize bleeding risks. ○ Monitor closely postpartum for delayed hemorrhage (may occur 4–5 days after birth). Nursing Considerations Recognize and assess clotting issues early to reduce postpartum hemorrhage risk. Monitor vital signs, bleeding, and urine output to detect complications. Educate and emotionally support patients and families, ensuring they understand the condition and its management. Infections Acquired During Pregnancy Sexually Transmitted Infections (STIs) Impact on Pregnancy: ○ STIs can cause long-term complications such as infertility, sterility, and psychosocial challenges like altered interpersonal relationships and reduced self-esteem. ○ Congenitally acquired infections may lead to severe neonatal outcomes, affecting both the quality and duration of life. Urinary Tract Infections (UTIs) Definition: Infection of structures within the urinary tract. Causes: ○ Primarily caused by Escherichia coli (80% of cases) Types of UTIs 1. Asymptomatic Bacteriuria: ○ Definition: Presence of bacteria in urine without symptoms; diagnosed when a clean-voided urine specimen contains ≥100,000 colonies/mL of a single organism. ○ Risks: If untreated, one-third of cases may progress to acute pyelonephritis. Associated with preterm labor, low-birth-weight infants, and increased maternal morbidity. ○ Treatment: Antibiotics such as amoxicillin, cephalexin, or nitrofurantoin. Suppressive therapy (e.g., nightly nitrofurantoin) may be considered for recurrent cases, excluding the last four weeks of pregnancy. 2. Cystitis: ○ Definition: Infection of the bladder characterized by dysuria, urgency, frequency, and suprapubic pain. ○ Symptoms: White blood cells (WBCs) and bacteria in the urine, sometimes with hematuria. ○ Treatment: A 3-day course of antibiotics like ampicillin, cephalexin, or trimethoprim-sulfamethoxazole is 90% effective. Phenazopyridine may be prescribed for symptom relief, with patient education about potential urine discoloration. 3. Pyelonephritis:  ○ Definition: A serious kidney infection, often requiring hospitalization and the second most common non-birth reason for hospital admission during pregnancy. ○ Symptoms: Abrupt onset of fever, chills, lumbar pain, and nausea. Tenderness at the costovertebral angles on palpation. ○ Complications: Sepsis, acute respiratory distress syndrome (ARDS), and preterm labor. ○ Treatment: Initial broad-spectrum IV antibiotics (e.g., ceftriaxone, ampicillin, gentamicin). Transition to oral antibiotics after clinical stabilization, completing a total of 7–10 days. Recurrence occurs in 20–30% of cases, prophylactic antibiotics (e.g., nitrofurantoin). Chapter 15: Pregnancy at Risk: Pre-existing Conditions Metabolic Disorders Diabetes Mellitus - Need strict blood glucose control → higher chance for baby being born with congenital abnormalities - Diabetics at high risk for congenital abnormalities and C-Sections → do more US and tests - Hypoglycemia risk is increased during pregnancy Preconception Counseling! - Optimize glycemic control - Begin folate supplementation → prevent neural tube defects - Assess medications and presence of complications - Contraception - Financial implications → frequent fetal and maternal surveillance Pathogenesis - Group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both Cause - Impaired insulin secretion - Inadequate insulin action in target tissues First Trimester/ early second trimester - Insulin needs reduced → because of increased pancreatic insulin production and increased peripheral sensitivity to insulin→ N,V, decreased food intake and decreased glucose transfer to baby = hypoglycemia Late second trimester - Insulin needs increase as placental hormones (cortisol and insulinase) act as insulin antagonists)  - Insulin resistance begins at 14-16 weeks Third Trimester - Insulin requirements gradually increase until 36 weeks gestation Day of Birth - Drop to approach pre pregnancy levels Breastfeeding - 25% less than pre pregnancy Maternal Risks and complications - DM Preterm labor and Birth Hypertension - Increased risk for developing pre-eclampsia (take aspirin starting at week 16 to reduce risks) Infections - More common and serious in diabetic patients - Inflammatory response, leukocyte function, and vaginal pH are all affected - Infection causes insulin resistance → DKA - Vaginal infections and UTIs are common Polyhydramnios - Frequently develops during third trimester Diabetic Ketoacidosis - Steroids cause DKA - Accumulation of ketones in the blood from hyperglycemia → DKA - Often during 2nd and 3rd trimesters - Occurs when blood gluc is over 11mmol/l Hypoglycemia - Increased risk - Hx or hypoglycemia massively increases risk - Maintain hypoglycemic awareness - Tight glucose control is critical Fetal and Newborn Risks Macrosomia - Large for gestational age (BW above 4000- 4500 g/ over nineteenth percentile - Increase in shoulder and trunk size → INCREASED RISK OF SHOULDER DYSTOCIA - C-section or slowed vag birth with vacuum extraction or forceps - Fetal pancreas responds to maternal HYPERGLYC @ 10-14weeks → by secreting insulin (growth hormone → macrosomia) Often cause birth injuries - Brachial plexus palsy, facial nerve injury, humerus/ clavicle fracture, cephalhematoma Spontaneous miscarriages - Common if poor glycemic control around conception and in first weeks of pregnancy Congenital abnormalities  - CNS → open spina bifida, anencephaly - Cardiac → VSDs + transposition of the great vessels Hypoglycemia at Birth - Influenced by maternal glucose control during the latter weeks of pregnancy and during labor and birth Antepartum Care - Utilize diabetic report card (track A1C targets for 4-6 weeks) → anything above 6.0 indicates elevated glucose levels Urinalysis and culture → UTIs, do if blood glucose is over 14 mmol or illness occurs - 24h urine collection -> test protein and creatinine clearance - Thyroid Function Tests - KEEP A1C below 7% - A1C goal (3.4-6.7) euglycemia First and Second Trimester - Prenatal visits → every 1-2 weeks Third Trimester - 1-2 visits per week Diet and Exercise - follow canada's food guide - Be active for 30-60 min daily Self Monitoring of Blood Glucose - Measure before breakfast, lunch and dinner, 2h after meals, at bedtime and in the middle of the night Insulin - Type 1 and 2 → multiple injections per day - Clear → cloudy Complications During Hospitalization  - Infection → hyperglycemia and DKA - Poorly controlled glucose in third trimester → hospitalization Determination of Birth and Mode of Delivery - Progress to term when good metabolic control is maintained and all fetal surveillance is normal - Do amniocentesis (check for fetal lung maturity) @38.5 weeks - If lungs are immature then postpone birth - C-section if compromised Fetal Surveilance Ultrasound - every 4-6 weeks (monitor fetal growth, est fetal weight, detect hydramnios or macrosomnia, presence of congenital abnormalities) Intra Pregnancy screening (IPS) and US @ 18-22 weeks - Assess neural tube defects Fetal echocardiography @20-22wks - Check for cardiac anomalies, common with poor first trimester gluc control Surveillance usually occurs in third trimester when risk is greatest Daily movement counts - Begin at 26-32 weeks gestation Nonstress Test (NST) - PRIMARY METHOD TO ASSESS FETAL WELLBEING - Assesses babies heart rate in response to movement Intrapartum Care - DM - Closely monitor blood glucose every hour when in active labor (btwn 4-7) - T1 +T2 on continuous insulin drip, kept in side lying position for perfusion - Assess dehydration, hypoglycemia, hyperglycemia - Epidural anesthesia for pain relief (no regional) - Encourage mobility - Telemetry to monitor fetus remotely Postpartum Care - DM - Reduce insulin dose (sliding scale) - Talk to lactation consultant → breastfeeding issues are normal with poor glycemic control (can delay lactogenesis and contribute to decreased milk production) - Increased risk for mastitis and post yeast infections - High chance for PPH and macrosomic babies (with poor glycemic control) - Contraceptives mess with blood glucose levels Thyroid Disorders Hyperthyroidism/ graves disease - Graves disease of hCG mediated hyperthyroidism responsible for 90-95% of cases - Signs at 4-8 weeks gestation  - Usually autoimmune - NO IODINE → S+S → mirror symptoms of first trimester - Severe NV, fatigue, heat intolerance, warm skin, losing weight Untreated hyperthyroidism → low birth weight, IUGR, prematurity, stillbirth, goiter and hyper/hypothyroidism PTs with Hyperthyroid increased risk of - Pre-eclampsia, HF, premature birth, stillbirth, growth restriction, miscarriage Start low-dose aspirin before 16 weeks to reduce Preeclampsia risks Hypothyroidism - Cause often iodine deficiency - Screen symptomatic patients - Treatments to increase TSH level Hypo mom → hypo baby when born Levothyroxone → safe for pregnancies - Increase dose as pregnancy goes along (frequently monitor TSH levels S+S - Maternal fatigue, weight gain, cold intolerance, decrease in exercise capacity, constipation, cool and dry, coarse hair, muscle weakness Causes - Pre-eclampsia., abruptions, stillbirth, miscarriage, weight gain, cool dry skin, muscle weakness, dry skin Cardiovascular Disorders - 15 percent of maternal mortality - Fever and infection can cause heart to decompensate and go into HF - Is cardiac output able to maintain during pregnancy and labor requirements cannot → decompensated → HF - Cardiomyopathy, valvular disease, congenital heart defect → cardiac decompensation CV changes that affect women with cardiac disease - Increased intravascular volume - Decreased systemic vascular resistance - Increased HR and stroke volume - Intravascular volume changes after birth Cardiac output peaks at 20-26 weeks of gestation (30-50 percent increase) Determine at 3 months then look for complications at 7-8 months → tells us how they will tolerate pregnancy and labor processes Classification of CV diseases Class 1 - asymptomatic without limitation to physical acidity Class 2 - symptomatic with slight limitation of activity Class 3 - symptomatic with marked limitation of activity Class 4 - symptomatic with inability to carry on any physical activity without discomfort Nursing management Assessment Signs of Decompensation → decreased respirations, shortness/difficulty breathing, tachypnea, low cap refill, BP decreases and HR increases, increased afterload, crackles in lungs, coughing, weak pulse, palpitations, Heart Murmurs - Put on telemetry - Give fluids (manage hyper/hypovolemic) - Labetalol to decrease BP - Decrease anxiety pharm and non-pharmacological reasons - Elevate head and shoulders - Epidural vagnial delivery → more numb to pain - SECOND TRIMESTER → best time for cardiac surgery - Postpartum → monitor for 48h postpartum Care - Therapy focused on minimizing stress on heart - Signs and symptoms of cardiac decomp - Nutrition and activity counseling - Anticoagulants → heparin (does not cross placenta) Obesity - 43.7% of women in canada are overweight - Achieve optimal body weight before conception to decrease risks - Bariatric surgery helps decrease risks - Increased risk of hiatal hernia, aspiration, wound dehiscence (opening) and DVT Antepartum Risks - Infertility → difficulty becoming pregnant - Increased spontaneous abortion risk, increased stillbirth risk - Attempt weight loss before pregnancy, once already pregnant → decreased efficacy - Regular exercise improves outcomes - Higher RISK for GDM and HTN → give low dose aspirin prophylaxis before 16 weeks for preeclampsia - May need repeat US for anatomy scan Intrapartum and Postpartum Risks - Increased risk for: shoulder dystocia, c-section, induction - Difficulty with EFM - Difficulty breastfeeding - Risk for PPH, wound dehiscence, DVT Anemia - Common in pregnancy 20-60% - Decreases 02 carrying from mom to baby - Increases stress of cardiac workload Anemia in Pregnancy - Hgb below 110g/l - Hct below 0.32 Physiological Anemia (hydremia) - diluted blood from increased CV and CO Iron Deficiency Anemia - Pts at with iron deficiency at risk for IDA - Vomiting, IBS, and bariatric surgery can impair iron absorption - Routinely screen at risk patients - Assoc with: Preterm births and Low birth weight infants Nurs - Diet alone cannot replace gestational iron losses Prevention → take 30mg/day iron supplements (fetal development and maternal stores) If ineffective → give 60-120 mg/day elemental iron - Blood transfusions if severe anemia to prevent fetal and maternal complications Folic Acid-Deficiency Anemia - Found in dark green leafy vegetables, citrus fruits, legumes and whole grains Folic acid deficiency during conception → neural tube defects, cleft lip + cleft palate - Rarely occurs in fetus  - Iron deficiency often occurs with folate deficiency - Give with vB12 → increases absorption, helps with pernicious anemia RDI → 0.4g/day → 1g/day Risks for folate deficiency - Significant hemoglobinopathies - On anticonvulsants - Multifetal pregnancies - Frequent pregnancies S+S - Shortness of breath, fatigue, pallor, lethargy, glossitis and skin roughness (associated with megaloblastic anemia) Pulmonary Disorders Asthma Goal → keep oxygenation of the fetus by preventing hypoxic episodes in the mother and fetus Associated with → preterm birth, pre-eclampsia, low birth weight, IUGR, Perinatal mortality Therapy objectives Monitor lung function Avoid or control asthma triggers Education Drug therapy Medications - Traditional ventolin/salbutamol may not be compliant with pregnancy safe medications → change to pregnancy safe medications S+S → SOB, increased RR, wheezing on expiration, coughing, dyspnea, phlegm Cystic Fibrosis - Infants of mothers with CF will be carriers - Exocrine glands produce excessive viscous secretions - Often associated with respiratory and digestive systems - Epidural or local analgesia is good Higher chance for → GDM (decreased insulin secretion and increased resistance), liver disease, and poor prognosis Monitor → pts weight, IUGR, blood glucose, hemoglobin, amniotic fluid, total protein, serum albumin, prothrombin time, fat soluble vitamins A and E Labour → monitor fluid and lyte balance to assess for sodium loss and hypovolemia RF in severe CF→ poor pre pregnancy nutritional status, pulmonary disease with hypoxemia, pulmonary HTN, LVR disease, DM NST → at 32 weeks if there is fetal compromise Integumentary Disorders - Dermatological disorders influenced by pregnancy Melasma (chloasma) Vascular “spiders” Palmar Erythema Striae Gravidarum Pruritus gravidarum - Generalized itching with no rash - Limited to abdomen (usually) - Caused by skin distention - Associated with multiple pregnancies - TRTMT → lube, topical antipruritics, oral antihistamines Pruritic urticarial papules and plaques of pregnancy (PUPPP - In Primigravidas mid-late third trimester - RF → obesity, htn, carrying male son - GOAL → relieve maternal discomfort - TRTMT → antipruritic topical, topical steroids, oral antihistamines Intrahepatic Cholestasis of Pregnancy (ICP) Char → generalized pruritis beginning in third trimester (usually on palms and soles) - Disruption in hepatic bile flow → build up → abnormal LFTs, jaundice, Preterm birth, stillbirth Trtmt → URSO → bile acid medication, helps liver process and excrete bile salt - Antihistamines (benedryl) NEUROLOGICAL DISORDERS Focal seizures - Brief loss of awareness without loss of consciousness Generalized seizures - Muscle rigidity, violent muscle contractions, loss of consciousness Epilepsy - Recurrent seizures often get worse - SEIZURE CONTROL #1 objective - Change medications → current ones could have teratogenic effects - Newborn vitamin K injections (decreases risk of brain hemmorrhage) TRTMT → meds to control seizures (IV phenytoin or midazolam) - Assess vitals and neuro status post → level of sedation, orientation, headache, language deficits, coordination, weakness/ paralysis, behavioural changes Risks → congenital malformations, intrauterine growth restriction MEds → 4mg/ day of folic acid highest dose (norm is 0.4-1g) Postpartum → decrease meds with seizures decreasing back to antepartum levels Complications → SUDEP Sudden unexpected death in epilepsy Risk factors → uncontrolled or frequent seizures, generalized tonic-clonic seizures Multiple Sclerosis  - Often in remission during pregnancy → can exacerbate in third trimester - May need vacuum/ forceps delivery → high UTI risk - Epidural anesthesia indicated TRTMT - Corticosteroids and bedrest and IVIG (acute exacerbation) Bell's Palsy - Acute idiopathic facial paralysis - Can be related to reactivation of HIV - Peaks in third trimester and postpartum - No effects on infants CM - unilateral facial weakness with max weakness 48h after onset, difficulty closing eye, hyperacusis (abnormally acute sense of hearing), pain around the ear Systemic Lupus Erythematosus - Autoimmune antibody production effects skin, joints, kidneys, lungs, serous membranes, CNS, liver and other organs - Reduce infection risk!!! - Need 6 month remission period before Conceiving - Stress triggers flare ups - NO NSAIDS → closes PDA inhibiting fetal 02 circulation - Increased pre Meds - Lowest possible prednisone dose (glucocorticoids) - Antimalarials (plaquenil) least risks to fetus Long term (glucocorticoid) med use causes → bone loss, gestational diabetes, HTN, pre-eclampsia, adrenal suppression Risk For - Preeclampsia - Stillbirth NURS - Frequent US (fetal growth) - Fetal assessment tests - Daily fetal movement counts - weekly/ twice weekly NSTs - BPP/ amniotic fluid assessments @32 weeks gest Myasthenia Gravis (MG) - Autoimmune motor (muscle) end-plate disorder - Progressive muscle weakness in eyes (droopy eyelid), face, tongue, neck, limbs, and respiratory muscles - Take folic acid supplements for 3 months pre-pregnancy  - If diagnosed wait a year to start treatments (glucocorticoids (prednisone), and acetylcholinesterase inhibitors (pyridostigmine) → stabilize body - Usually tolerate labour well - May need forceps or vacuum delivery NURS - Prevent UTIs with prophylactic antibiotics → decreased motor function makes it hard to push → cant empty bladder → may need catheter and ABs to prevent infection - UTI can lead to miscarriages - Give oxytocin to help with contractions - Give IVIG for severe weakness - Babies stay in NICU for 48-72 hours to observe for transient neonatal MG Assesment - NST - BPP Spinal Cord Injury Chronic effects → autonomic dysreflexia (acute uncontrolled HYPERTENSION), impaired pulmonary function, chronic pulmonary or GU infections, anemia, osteoporosis, decubitus ulcers RISK → DVT, pulmonary embolism, ulcers, UTI Induction of Labour → no uterine activity felt or no contractions present - Vaginal birth is preferred - Lesions above T6 → increased AD risk Postpartum - Ensure bladder emptying → minimise UTI and AD risk HIV and AIDS Pregnancy risks - Pregnancy does not accelerate condition - Need strict adherence to antiretrovirals - Mom on antivirals → 2%change of baby getting it - NO BF → Can transmit through labour and breastfeeding - Place skin to skin after birth Prenatal counselling → decrease risk for transfer to baby - Assess for high risk behaviour - Get prenatal care immediately IF HIV positive get Vaxx → hep b, pneumococcal infection, haemophilus B influenza and viral influenza → because of immunocompromisation risk Nursing Care Management - No episiotomies/lacerations → keep membranes intact and prevent infected blood from going to baby - If membranes brea NO forceps or vacuum use (increases chances of bleeding) - Treat with antiretroviral therapy - Test for other STIs → hepatitis - Treat opportunistic infections with specific meds (from immunosuppression) → get culture - Make efforts to decrease NBs exposure to blood and fluids - Wipe off baby immediately after birth, use PPE - Infection control techniques Mental Health Disorders in Pregnancy - Impacts QOL of and well-being of parents, when untreated can increase risk of chronic MI MI in preg and postpartum is linked with complications for the child: - Growth and development - Preterm birth - Low birth weight - Delayed development (cognitive, behavioural, emotional) - Puts child at higher risk for developing own MH issues later Any type of MH issue can affect pregnant and postpartum individuals Common → depression, anxiety, ocd, trauma, stress disorders Less common but severe → bipolar, psychotic disorders Alcohol and substance disorders may be present on their own or with MH issues Diagnostic - Same as nonpregnant persons Transient mental health concerns - Adjustment disorder related to parenthood transition - Symptoms resolve with support and resolution of stressors (sleep deprivation, difficulty breastfeeding) - Occur within 3 months and resolve in 6  - Supportive care → no formal therapies or medication Mental Health issues Requiring Additional Clinical Attention and Interventions Perinatal period → depression, anxiety, more severe forms → bipolar, postpartum anxiety, postpartum psychosis 5 A’s of MH in pregnancy → screen at every visit Ask Advise - education Assess - severity of concern Assist - recommending or implementing care Arrange - follow ups and modifications to treatment as needed If untreated Mat depression and Anxiety can affect The pregnancy → poor nutrition and medical care, increased smoking or substance misuse Newborn → small for gest age, preterm birth, increased NICU admission, low BF rates Infant development → low quality mother infant interactions -> emotional, behavioural and academic problems Maternal Mental Health → higher chance of paternal depression if there is maternal depression Non pharm treatment → first line - Counselling, CBT, support groups MEDS SSRI + SNRIs - Most common - Balance risks and benefits of effects on baby vs moms mental state Poor neonatal Adaptation Syndrome (PNAS) - ⅓ newborns exposed to SSRIs or SNRIs in utero  - Mild and self limiting - Persistent pulm HTN of newborn and congenital heart defects are rare Low levels of SSRIs and SNRIs are compatible with breastfeeding Not officially linked to autism and adhd → inconsistencies in research Substance Use in Pregnancy - High risk factor for adverse outcomes - Less likely to seek prenatal care - Increased risk of preterm labour, premature rupture of membranes and spontaneous abortion - High chance of preterm, low birth weight, IUGR, withdrawal symptoms - Alcohol and drugs easily pass from mother to baby through placenta - High chances of unintended pregnancies Legal - Can only report if child is at risk - Non Judgemental and harm reduction model of care Smoking → vasoconstriction and carbon buildup decreased fetal oxygenation - Bleeding complications - Miscarriage - Stillbirth - Prematurity - Low birth weight - Sudden infant death syndrome - Vapes are bad but need more research Alcohol - Freely crosses placenta and is teratogenic to fetal brain - No exact dose response-relationship has been established - Fetus cannot metabolize alcohol → relies on mom for clearance (nutrition, genetics and BW effect this) - Binge drinking has more potentially more negative effects than casual drinking (four drinks in a sitting vs 4 drinks in 4 days - Give benzodiazepines to reduce seizure risk Baby has withdrawal effects in first 24h → highly excitable increased reflexes, tremors, seizures → next 48h is super tired → next 48h in normal state ***OPR T-ACE screening tool Opioids + Heroin - Injected smoked or snorted - Higher risk of hepatitis - Heroin crosses placenta, use can lead to several antenatal and neonatal complications - Demonstrate withdrawal symptoms within 24-48h after birth - Take harm reduction approach → better care, higher birth weights Buprenorphine, Methadone or Suboxone - Cause withdrawal symptoms 30-60 hours after birth → 28 days - No association between doses and withdrawal severity - Leads to improved prenatal care, higher birth weight, and increased rates of baby being discharged home with mother Patient focused psychosocial and behavioural counseling Amphetamines + methamphetamines (ectasy, MDMA, ice, crystal) - cause withdrawal symptoms in NEONATE - 24h → 10 days after birth → shrill cry, jerkiness, diaphoresis and sneezing Caffeine - Stimulant - Can affect mood and daily activities by producing anxiety and sleeping difficlty - High intake → low birth weight and miscarriage risk Cannabis - Crosses placenta and increases maternal carbon monoxide levels → less fetus oxygen - Can affect growth and behaviour development → long term learning and behavioural difficulties Cocaine - CNS stimulant and peripheral sympathominetic - Some infants have minimal withdrawal sympt - Can cause Placental Abruption, stillbirth, prematurity, SGA - IDENTIFY → goes for a smoke during labour and comes back with a placental abruption Hallucinogens - Alter cerebral functioning, perception, mood and cognitive processes - Little research on HALL effects oninfants - Most hall cross placenta and have potential to cause harm and negative neurobehaviroual effects on infant Substance use Intrapartum Management - Take methadone or suboxone → still need pain management (additional meds) - Take daily dose of opioid agonist treatment to avoid withdrawal - NO narcotic antagonists (NARCAN, NALOXONE) → contraindicated for women with opioid disorder → puts mom and baby into withdrawals (can kill baby in utero) Nursing Care MGMT - Communicate consequences of drug use, recommend cessation - Harm reduction → methadone/suboxone treatment Promote - Maternal infant attachment → skin to skin, swaddling, rocking, BF - Breastfeeding → drugs go through breastmilk helping baby wean faster Discharge - Need extra support due to complex medical and social needs - SOCIAL work and CPS may be involved - Examine Social issues and caring for infant before discharge → ensure no negative follow ups Postpartum Follow-Up visits - Dependant on alcohol, tobacco and other drugs may need medical detox and supportive withdrawal mgmt postpartum - Screen and monitor for postpartum mood and anxiety disorders Chapter 20: Labour and Birth at Risk Preterm labour starts between 20 and 37 weeks of pregnancy, with changes in the cervix and regular contractions. Preterm birth: Any birth before 37 weeks of pregnancy. Late Preterm Birth Most preterm births happen between 34 and 37 weeks (called late preterm). Higher chances of early death and long-term health problems compared to full-term babies. Preterm Birth vs. Low Birth Weight (LBW) - Preterm Birth: Baby is born before 37 weeks of pregnancy, regardless of weight. - Low Birth Weight (LBW): Baby weighs 2,500 g or less at birth, regardless of gestational age. Preterm birth is more dangerous because the baby has less time to develop fully in the uterus. LBW can happen for reasons other than preterm birth, such as poor fetal growth (intrauterine growth restriction (IUGR: Poor growth inside the uterus). Conditions like: Gestational hypertension. Poor maternal nutrition. - Babies born at term (37+ weeks) can still have LBW due to these factors. - Some preterm babies weigh more than 2,500 g (e.g., babies of patients with uncontrolled diabetes). Improved pregnancy dating methods now help differentiate between issues caused by gestational age and those caused by birth weight. Spontaneous vs. Indicated Preterm Birth: Happens naturally due to early labour processes. Causes include: Preterm labour (with intact membranes). Preterm premature rupture of membranes (preterm PROM). Cervical insufficiency (weak cervix that opens too early). Amnionitis (infection of the amniotic sac). Indicated preterm births are iatrogenic, because they occur as a means to resolve maternal or fetal risk related to continuing the pregnancy. - Planned by medical professionals to address risks to the mother, fetus, or both. - Accounts for 25% of preterm births. - Causes include medical or obstetrical issues like severe hypertension, fetal distress, preeclampsia, or placenta problems Spontaneous Preterm Labour and Birth Risk Factors Social Determinants of Health: Poverty, lack of education, poor access to prenatal care, and disadvantaged living areas. Age: Higher risk for patients under 18 or over 35 years old. Genetics: People born prematurely are more likely to have preterm births themselves. Assisted Reproductive Technology (ART): Increases rates of multifetal pregnancies and preterm births. Infections: Includes urinary tract infections (UTIs), intra-abdominal infections (e.g., appendicitis), and genital tract infections. Weak link between periodontal disease and preterm birth (recommend good dental care).  Uterine and Placental Issues: Uterine abnormalities or the placenta problems can trigger early labour. Vaginal bleeding after the first trimester increases risk, especially with repeated episodes. Other Factors: Stress, uterine overdistension (e.g., from twins), decreased progesterone, and inflammation of the uterus. Predicting Spontaneous Preterm Labour and Birth Fetal Fibronectin Test (fFN): A biochemical marker (a "glue") found in cervical and vaginal secretions. Presence of fFN between late 2nd and early 3rd trimester may indicate inflammation linked to preterm labour. Key Use: ○ Negative fFN test = low chance of preterm labour. ○ Helps reduce unnecessary hospital stays and interventions. Cervical Length Measurement: Short cervical length can predict preterm labour (less than 30 mm increases risk). Preterm cervical shortening happens over weeks, so it's not highly accurate for predicting imminent birth. Combining Tests: Using both fFN levels and cervical length measurements increases accuracy in identifying those at risk for preterm labour within 7 days. Nursing Care and Interventions Assessment: Ongoing Risk Assessment: Holistic focus on health (nutrition, exercise, stress management). Recognize early signs of preterm labour, as they may resemble normal pregnancy discomforts. Prevention: 1. Primary Prevention: ○ Focus on promoting healthy lifestyles and addressing risk factors (e.g., smoking cessation reduces preterm labour risk). ○ Preconception counselling for patients with a history of preterm birth. 2. Progesterone Supplementation: ○ For patients with a history of preterm birth or a short cervix ( 4,000 grams or 8 lbs, 13 oz). Complications: This can increase the risk of shoulder dystocia (difficult delivery due to the baby's large size), birth injuries (e.g., fractures, nerve palsies), and the need for a cesarean section. Hypoglycemia After birth, the infant's insulin production remains high due to exposure to elevated glucose levels in utero. When the infant is no longer receiving glucose from the placenta, their insulin levels can cause a rapid drop in blood sugar. Symptoms: Symptoms include jitteriness, poor feeding, lethargy, and in severe cases, seizures. Management: Early feeding (breastfeeding or formula) and intravenous glucose administration to correct hypoglycemia. Respiratory Distress Syndrome (RDS): Infants born to mothers with GD may have delayed lung maturation due to high levels of insulin, which can interfere with surfactant production, leading to RDS. Jaundice  Cause: Infants of mothers with GD are at increased risk of developing jaundice due to the rapid breakdown of red blood cells (increased RBC turnover) and liver immaturity. Polycythemia (Increased Red Blood Cell Count): Hyperglycemia in the mother leads to fetal hypoxia, which triggers an increased production of red blood cells to compensate for the reduced oxygen supply. This can lead to polycythemia, where the blood becomes thicker. Complications: Polycythemia increases the risk of hyperbilirubinemia, hypoglycemia, and respiratory distress. Cardiovascular Prolonged exposure to high maternal blood sugar can affect fetal heart development, leading to structural heart defects such as congenital heart disease. Symptoms: May not be immediately obvious but can lead to murmurs, cyanosis, or poor feeding if significant. Increased Risk of Birth Defect/Born Preterm Poorly controlled gestational diabetes in early pregnancy can increase the risk of congenital anomalies, especially neural tube defects, cardiac defects, and caudal regression syndrome (incomplete development of the lower spine and spinal cord). GD can increase the risk of preterm birth Complications: Preterm infants can have respiratory distress, hypoglycemia, and poor feeding, Inc Risk Obesity Infants of mothers with gestational diabetes may have an increased risk of developing obesity, type 2 diabetes, and metabolic syndrome later in life. Risk: This is related to the in-utero exposure to high glucose levels, which can alter metabolism and increase the likelihood of insulin resistance in childhood or adulthood. Chapter 29: The Newborn at Risk: Acquired and Congenital Conditions Chapter 29 Final Breakdown - 9 Questions, 2 SATA, 1 Calculation Acquired and Congenital Problems Birth Trauma - A physical injury sustained by a newborn at birth. These can result from factors like difficult labor, excessive force, or complications such as oxygen deprivation. Most common types include brachial plexus injury, fractures, and cerebral palsy, with varying severity and long-term effects. ~ Generally use an US to determine extent of trauma in utero or shortly after birth, elective c section can help avoid certain injuries - Skeletal Injuries - Clavicle Bone fracture is most common fracture during delivery - will often result in absence of Moro Reflex (when baby will extend their arms out when they are falling)  - Skull fracture can result if your using forceps to help the fetal head get through the pelvis when infant in cephalic presentation or repeated physical contact of the baby's head against maternal symphysis pubis 😳 - Types of Skull Fractures: Linear and Depressed Fractures. A linear skull fracture is a simple crack in the bone, typically without displacement, and usually heals without major complications. A depressed skull fracture :( occurs when a portion of the skull is pushed inward, (the skull looks like it got hit with a fucking ball) potentially causing brain injury or bleeding. Depressed fractures require more urgent medical intervention to prevent further damage, while linear fractures are generally less severe but still require monitoring. *Depressed Fracture can result in increased ICP if an artery on the grove of the undersurface is torn as a result of the fracture. Any fracture at the base of the skull can lead to severe hemorrhage and may need transfusion to replace blood loss Uncomplicated fractures in newborns generally heal quickly, immobilized with splint, sling, swaddling. Nurses should help the mother with feeding and changing so the infant is not injured Peripheral Nervous System Injuries Baby presents with odd shoulder, arm, and neck relation? - Could be a brachial plexus injury results from trauma to spinal roots of the fifth cervical to first thoracic. Important to prevent contractures, maintain correct arm placement. - Erb palsy: Damage to upper brachial plexus, a network of nerves controlling the arm and hand, leading to weakness or paralysis in the affected limb. Often due to excessive pulling or shoulder dystocia, lateral  traction from head and neck away from shoulder as infant passes through pelvic inlet. Most infants with Erb's palsy recover with physical therapy, but severe cases may require surgical intervention. Arms are kinda limp, adducted and internally rotated - Brachial palsy: Similar to Erbs, lower plexus, hand paralysis, wrist drop and relaxed fingers, Moro Reflex also absent, avulsion can result in permanent damage (forceable tear) - Facial nerve paralysis: Pressure on Cranial Nerve 7, during birth, abnormalities most noticeable during crying - loss of facial movement on one side, eye won’t close all the way, dropping mouth. Assist in suckling and feeding, artificial tears to avoid drying of the conjunctiva - Phrenic nerve paralysis: “Diaphragmatic paralysis” - paradoxical chest movement, you’ll need an US to confirm. Often presents with brachial palsy, CYANOSIS and RESP DISTRESS COMMON due to decreased diaphragmatic control , THE PHRENIC NERVE IS UNILATERAL, THE AFFECTED ONE SIDE OF LUNG WON'T EXPAND AS MUCH, POSITION ON AFFECTED SIDE TO COMPENSATE. Neurological Injuries - Intracranial hemorrhages: Very low birth weight and preterm infants are at risk for intraventricular or periventricular hemorrhage. Bleeding within the brain can result from traumatic delivery, prematurity, or medical conditions like hypoxia. In newborns, these hemorrhages are most commonly seen in premature infants due to their fragile blood vessels,  particularly in that periventricular area. Symptoms may include lethargy, poor feeding, seizures, or abnormal muscle tone, though severe cases can lead to long-term neurological damage. Can cause long term brain damage - Hypoxic Ischemic Encephalopathy: brain injury caused by hypoxia and ischemia to the brain during or around the time of birth. It can result from prolonged labor, cord prolapse, placental abruption, or if mom has preeclampsia. It can cause a range of neurological impairments, from mild developmental delays to severe cognitive and motor disabilities, death. The severity of the condition depends on the timing, duration, and extent of the oxygen deprivation. Treatment often involves therapeutic hypothermia (cooling therapy) to reduce brain damage if initiated within the first 6 hours of life. - Cerebral palsy: permanent movement disorders caused by abnormal brain development or damage to the brain during fetal development or shortly after birth. The condition typically results from factors such as oxygen deprivation, brain injury, premature birth, or infections during pregnancy. Symptoms of CP can vary widely, but commonly include spasticity, poor coordination, and difficulty with motor skills, such as walking or feeding. LIFELONG - Seizures: Neonatal seizures often present as subtle signs, such as eye deviation, lip smacking, or rhythmic jerking of limbs, and can be difficult to recognize in the early stages. Treatment often involves antiepileptic  medications and addressing the underlying cause of the seizures, such as correcting metabolic imbalances or treating infection. EEG MRI - Hydrocephalus: abnormal accumulation of CSF within the ventricles of the brain, leading to increased ICP and potential brain damage. Symptoms: enlarged head, bulging fontanels, irritability, poor feeding, vomiting, and lethargy - Spinal cord injury: Cervical spinal cord injury can result in complete paralysis or death Sepsis Microorganisms in the blood or other tissues, life-threatening infection that can rapidly progress, causing systemic inflammation and organ dysfunction. It (E.Coli, GBS), AT RISK IF IGM DOES NOT CROSS THE PLACENTA, neutrophils in infants are immature and do not function to the same extent as older children to ward off infection. Treat with abx, fluid management, monitor vitals. - Patterns - Early onset (congenital) within 24-72 hours after birth. Often caused by E. Coli - Late onset after 72 hours, generally hospital-acquired infection. ie) Staph A, Candida - Apnea, tachypnea, grunting, nasal flaring, hypotension, tachycardia, lethargy, hypotonic, seizures, vomiting, pallor, petechiae General prevention of Infections: hand hygiene (duh no shit), change IV and NG tubing. Newborn skin, its secretions, and normal flora are a natural part of a baby's defense system. Warm water should be used to wipe away meconium from the infant 's face, do not rub vernix caseosa too hard because you'll damage skin and could cause infection. Encourage breastfeeding, colostrum has IGA in it Maternal Infections **Foul smelling amniotic fluid: chorioamnionitis: an infection of the amniotic sac and membranes surrounding the fetus, caused by bacteria ascending from the vaginal area into the uterus. It is often associated with prolonged labor, premature rupture of membranes, or maternal infections, and can lead to complications such as preterm birth, fetal distress, or neonatal infection. (premature membrane rupture) TORCH Complex for Congenital VIRAL Infections - Toxoplasmosis - Other: ie) Hep B, Parvovirus, HIV, West Nile Virus - Rubella - Cytomegalovirus (CMV) - Herpes simplex virus (HSV) ALL can be transmitted from mother to fetus during pregnancy. These infections may lead to conditions such as microcephaly, hearing loss, vision problems, and developmental delays in the infant. This mnemonic is used to remember what to screen for not necessarily individual treatment or symptoms as they're all fairly similar in presentation, Give vaccinations and prophylactic treatment, acyclovir all that fun shit. As a nurse Goal is to identify causative organism, routine hygiene precautions, pregnant health care provider precautions ie) unsure mom was immunized, specimen collection. Hemolytic Disorders Hemolytic disease occurs when blood groups of the mother and newborn are different. (probably on test) – Rh incompatibility: rH ( - ) mom with rH ( + ) baby – ABO incompatibility: O mother, A or B or AB baby – Other hemolytic disorders - G6PD: an inherited enzyme disorder that affects red blood cells, making them more vulnerable to hemolysis under certain stressors, such as infections or specific medications. More common in males and can lead to episodes of anemia, jaundice, and fatigue Occur when maternal antibodies are present naturally or form in response to antigen from fetal blood crossing placenta and entering maternal circulation, ALL RESULT IN RBC BREAKDOWN May need intrauterine blood transfusion, exchange transfusion when born, or intensive phototherapy Congenital Abnormalities – Congenital heart disease:structural heart defects present at birth, which can affect the heart's ability to pump blood effectively. Involve the heart's chambers, valves, or blood vessels and may lead to symptoms such as cyanosis, poor feeding, rapid breathing, and failure to thrive. Types of CHD include Atrial Septal Defects, Ventricular Septal Defects, and Tetralogy  of Fallot - consists of four structural abnormalities: a ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. Diagnosed via ECHO, CXR, Cardiac MRI in extreme cases. SPO2 testing via 1 pulse ox on one hand one pulse ox on opposite foot) - want o2 sats above 95 with no more than 3% difference btwn hand and foot - test for ECHO if sats less than 95% – Abdominal wall defects: incomplete closure of the abdominal wall during fetal development, leading to the protrusion of abdominal organs outside the body. The two most common types are omphalocele and gastroschisis. In omphalocele, the abdominal organs protrude out of the stomach and are contained within a sac covered by a membrane, while in gastroschisis, the organs are exposed directly to the environment without a protective sac. – Imperforate Anus: the anus and rectum do not develop properly, resulting in a blockage or absence of the anal opening. This defect can range from a mild form, where there is a small membrane covering the anal opening, to a more severe form, where there is no visible anal opening at all (no asshole) – Neural tube defects: neural tube eventually forms the brain and spinal cord, if defect it fails to close properly during early fetal development. Types: Spina bifida is characterized by an incomplete closure of the spinal column, leading to varying degrees of paralysis and sensory loss, while Anencephaly is a more severe condition in which the brain and skull do not develop properly, typically resulting in death shortly after birth. Infants with spina bifida may also have associated complications like hydrocephalus,  urinary incontinence, and orthopedic issues. NTDs detected prenatally through ultrasound or maternal blood tests – Cleft Lip or Palate: can affect the hard palate, soft palate, or both. This defect occurs when the tissues that form the palate do not fuse properly during fetal development. Cleft palates can occur alone or in combination with a cleft lip, may cause difficulties with feeding, speech development, ear infections, and hearing problems. The severity of a cleft palate can vary, and while mild cases may require only minimal intervention, more severe cases typically require surgical repair and ongoing speech and dental therapy. – Clubfoot: newborn's foot is twisted out of shape or position, typically turning inward and downward. Bracing or surg TYPES OF NEWBORN SCREENING Inborn Errors of Metabolism – Phenylketonuria: failure to thrive, frequent vomiting, irritability, hyperactivity, cognitive impairment. Needs low diet in phenylalanine and medications – Galactosemia: three enzyme deficiencies. Vomiting, diarrhea, therapy, weight loss. Eliminate all lactose including breastmilk – Hypothyroidism: poor feeding, lethargy, prolonged jaundice, bradycardia, cyanosis. Needs medications – Biliary atresia: the bile ducts are blocked or absent, preventing bile from being properly drained from the liver. PTS OFTEN HAVE JAUNDICE. Blood testing includes watching for elevated liver enzymes, such as bilirubin, ALP, AST, and ALT.. A bilirubin test specifically can help determine if the  jaundice is due to liver problems. ABDO US, Hepatobiliary Scintigraphy (HIDA scan): A HIDA scan is a nuclear imaging test that tracks the flow of bile from the liver to the gallbladder and intestines. If bile does not flow normally, it can confirm the diagnosis of biliary atresia. NSO Blood Screen – Metabolic diseases - where the body is unable to break down certain substances in foods, like fats, proteins, or sugars. – Endocrine diseases - where the body produces too much or too little of certain hormones. – Sickle cell disease - which affects the movement of oxygen in the blood. – Cystic fibrosis - which causes problems with breathing and growth. – Severe combined immune deficiency - which affects the body’s ability to fight infections. – Spinal muscular atrophy - which causes muscle weakness and wasting. Neonatal Abstinence Syndrome Intrauterine exposure to drugs may lead to neonatal intoxication or withdrawal. However it Is not always illicit drug use. The presentation of NAS can be similar to neonatal sepsis hypo or hyperglycemia, hypocalcemia or an intracranial hemorrhage. If NAS is left untreated, seizures from withdrawal and intracranial hemorrhage may occur, seizures have also been associated with non-narcotic withdrawal.  - Babies with NAS often present with Hyperactive reflexes, supertonus, high pitched shrill cry, sweaty (babies normally don’t sweat). NAS is sometimes associated with maternal substance use during pregnancy, including opioids like heroin, prescription painkillers, and methadone, but can also occur with exposure to other substances such as alcohol, benzodiazepines, or cocaine. Treated with pharmacologic withdrawal therapy (such as morphine or methadone) and supportive care (such as swaddling, feeding support, and a calm environment) - Symptoms may occur within the first 24 hours of life up to 47 days after birth. Per Slides: Assessment should be performed every 2-4 hours AFTER the infant has fed and clustered with other care (vitals, weight, etc) - Assessments should include the previous 2-4 hours since the last assessment and include input from all care team members especially the mother/guardian - Some centres use Modified Finnegan Scoring tool which looks at RR,  HR, temperature, tremors, crying, sneezing, yawning, stool consistency etc as signs of withdrawal. - Other centres use Eat, Sleep Console which looks at if the infant can feed a normal amount, sleep for 1 hour post feed, and can be consoled within 10 minutes - Cannot give Narcan