Maternal and Child Health Nursing NCMA 219 Lecture PDF

MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE CU 1 - GENETIC ASSESSMENT AND Genetic Disorders COUNSELLING Genetic disorders - a defect in the structure or GENETIC ASSESSMENT AND number of g...

MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE CU 1 - GENETIC ASSESSMENT AND Genetic Disorders COUNSELLING Genetic disorders - a defect in the structure or GENETIC ASSESSMENT AND number of genes or chromosomes COUNSELLING Inherited or genetic disorders can be passed patient’s who are at risk of an inherited disorder from one generation to the next. should have an access to genetic counselling for Genetic disorders occur when an ovum and advise, resources, and support. sperm fuse in the meiotic division (ovum and sperm) NATURE OF INHERITANCE Other genetic disorders do not affect life in Genes– are the basic units of hereditary that utero, result of the disorder becomes apparent determine both the physical and cognitive only at the time of fetal testing or after birth characteristics of people Some genetic abnormalities are so severe that Composed of DNA (Deoxyribonucleic acid) normal fetal growth cannot continue past that Genetics - the study of how and why point. chromosomal disorders occur In- vitro fertilization (IVF) can examined for Cytogenetics - is the study of chromosomes by genetic disorders of single gene or chromosome light microscopy and the method by which concerns before implantation. (egg and sperm) chromosomal aberrations are identified MENDELIAN INHERITANCE: DOMINANT AND GENETIC DISORDERS RECESSIVE PATTERNS Nature of Inheritance Homozygous - a person has two healthy genes Mendelian Inheritance (one from the mother and one from the father) - Dominant Patterns both are the same +,+ / -,- Recessive Patterns Heterozygous – a person with differ genes (a Inheritance of Disease healthy gene from the mother and an unhealthy gene from the father or vice versa) - both are Nature of Inheritance different +,- In humans, each cell, contains 46 1. Autosomal Dominant Disorders - either has chromosomes (22 pair of autosomes and 1 pair two unhealthy genes (homozygous dominant) or of sex chromosomes). heterozygous with gene Spermatozoa and ova each carry only half of causing the disease - one faulty gene, can cause disorder Only one faulty gene needed to have disorder the 23 chromosomes. Autosomal dominant (Heterozygous)– free Each chromosome in the sperm cell, have from the traits, the chances are 50%, child would similar size and shape and function (autosome, have the disorder or would be disease and or homologous chromosome) in the ovum. carrier free - 50-50 chances Two heterozygous - 25% chance of a child’s A person’s genotype - his or her actual gene being disease and carrier free, 50% chance composition would have the disorder, 25% child would have A person’s phenotype - his or her outward homozygous dominant (incompatible with life) appearance or the expression of the genes. 25% chance the child will be healthy and not a carrier. A person’s genome - is the complete set of 50% chance the child will have the disorder. genes present which is about 50,000 - 100,000 25% chance the child will inherit two faulty genes (homo), Normal Genome: which is usually fatal. 46 XX – female with 46 total chromosomes 46 XY– male with 46 total chromosomes CHARLIZE M. TABUDLONG 1 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE 1. AUTOSOMAL DOMINANT DISORDERS 3. X-Linked Dominant Inheritance Dominantly Inherited pattern is present in the Characteristics: family: 1. All individuals with the genes are affected (the a. One of the parents of a child with the disorder gene is dominant) - if you have dominant gene, you’re also will have the disorder. affected b. The sex of the affected individual is 2. All female children of affected men are unimportant in terms of inheritance. affected, all male children of affected men are c. There is usually a history of the disorder in unaffected - affected man, pass it all to their daughters, other family members. but none of their sons 3. It appears in every generation. 4. All children of homozygous affected women 2. AUTOSOMAL RECESSIVE INHERITANCE are affected. 50% of the children of diseases do not occur unless two genes for the heterozygous affected women are disease are present affected. 25% chance a child born will be disease and mother > 2 faulty genes (homo) > all children will have carrier free (homozygous dominant for the disorder healthy gene) mother > 1 faulty gene (hetero) > half children will have 50% chance a child will be like the parents free disorder of disease but carrying the gene (heterozygous) 25% chance the child will have the disease 4. X-Linked Recessive Inheritance - disorders (homozygous recessive) are recessive, and inheritance of the gene from both parents is incompatible with life. - recessive; meaning both parents must pass on the gene for it to 1. Both parents of a child with the disorder are affect their child clinically free of the disorder. ▪ the disease will be manifested by any male 2. The sex of the affected individual is children who receive the affected gene from unimportant in terms of inheritance. their mother. - if male child gets the affected gene from 3. The family history for the disorder is negative– his mother, he will show symptoms of the disease that is no one can identify anyone else who had - if he inherits the gene from both parents, it is usually fatal. it (horizontal transmission) 4. A known common ancestor between the 1. Only males in the family will have the disorder. parents sometimes exists. Both male and female 2. A history of girls dying at birth for unknown came to possess a like gene for the disorder. reasons often exists (females who had the affected gene on both X chromosomes) 2. AUTOSOMAL RECESSIVE INHERITANCE 3. Sons of an affected man are unaffected. a. Cystic fibrosis - affects the lungs; causes breathing 4. The parents of affected children do not have problems the disorders. b. Adrenogenital syndrome - hormonal imbalance from adrenal issues; affects growth and development 4. X - LINKED RECESSIVE INHERITANCE c. Albinism - little or no skin pigment; very light skin and DISORDER eye sensitivity 1. Hemophilia A (blood factor deficiencies) d. Tay-Sachs disease - nerve cell breakdown; development delays 2. Color blindness e. Galactosemia - can’t digest galactose (milk sugar) 3. Fragile X syndrome - a cognitive challenge f. Phenylketonuria - can’t brekdown phenylalanine; syndrome brain damage 4. Duchene muscular dystrophy g. Limb-girdle muscular dystrophy - muscle ( Pseudohypertropic ) weakness in hips and shoulders; affects movement h. Rh Factor incompatibility - mother’s blood type conflicts with baby’s; can harm the baby if not managed CHARLIZE M. TABUDLONG 2 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE 5. Multifactorial (Polygenic) Inheritance 3. Translocation Abnormalities - a child gains an occur from multiple gene combinations additional chromosome through another route combined with environmental factors. e. g Down Syndrome Many childhood disorders tend to have higher - A piece of one chromosome attaches to another than usual incidence (heart disease, diabetes, chromosome. This can lead to conditions like Down Syndrome. cleft lip and palate, neural tube disorders) 4. Mosaicism down syndrome - an abnormal disorders is unpredictable condition when the nondisjunction disorder Do not follow the Mendelian Laws occurs after fertilization No set patterns in family history different cells in the body will have different chromosome counts. 6. IMPRINTING The extent of the disorder depends on the Imprinting - refers to the differential expression proportion of tissue with normal chromosome of genetic material and allows researchers to structure to tissue with abnormal chromosome identify chromosomal material has come from constitution. the male or female parent. - some genes work - This occurs when nondisjunction happens after differently depending on whether they come from your fertilization, leading to different cells in the body having mom or dad different chromosome counts. The severity depends on how many normal versus abnormal cells are present. CHROMOSOMAL ABNORMALITIES (CYTOGENIC DISORDERS) CHROMOSOMAL 5. Isochromosomes - a chromosome ABNORMALITIES (CYTOGENIC DISORDERS) accidentally divides by a horizontal one, a new chromosome with mismatched long and short 1. Nondisjunction Abnormalities Chromosomal arms can result. abnormalities occur if the division is uneven It has the same effect as a translocation (nondisjunction). abnormality when an entire extra chromosome The result may be that one new sperm cell or exists ovum has 24 chromosomes and the other has - This is when a chromosome divides unevenly, resulting only 22. in one chromosome with two long arms and another with two short arms. It’s similar to translocation because it If a spermatozoa or ovum with 24 or 22 creates an extra chromosome. chromosomes fuses with a normal spermatozoa or ovum, the zygote will have either 47 or 45 GENETIC COUNSELING chromosomes PURPOSES: 45 chromosomes does not compatible with life, 1. Provide concrete, accurate information about and the embryo or fetus probably will be aborted inherited disorders. - This happens when chromosomes don’t split evenly during cell division. One egg or sperm may have 24 2. Reassure that their child may inherit a chromosomes, and another may have 22. If these fuse particular disorder that the disorder will not occur. with a normal one, the zygote could have 47 or 45 3. Allow people who are affected by inherited chromosomes. Having 45 is usually not viable for life. disorders to make informed choices about future reproduction. 2. Deletion Abnormalities - a chromosome 4. Educate about inherited disorders and the disorder in which part of a chromosome breaks process of inheritance during cell division, causing to have the normal 5. Offer support by skilled health care number of chromosomes plus or minus an extra professionals to people who are affected by portion of a chromosome. - A piece of a chromosome genetic disorders. breaks off during cell division. This can result in having the normal number of chromosomes but missing part of one. CHARLIZE M. TABUDLONG 3 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE COUPLES MOST APT TO BENEFIT FROM 2. Physical Assessment GENETIC COUNSELING a. Physical assessment of any family member COUPLES WHO ARE MOST APT TO BENEFIT with a disorder, child’s siblings, the couple FROM REFERRAL FOR GENETIC TESTING seeking counseling is needed. OR COUNSELLING b.During inspection, pay particular attention to 1. A couple who has a child with a certain body areas (space between the eyes; the congenital disorder. height, contour, shape of ears, number of fingers 2. A couple whose close relatives have a and toes, presence of webbing) child with a genetic disorder Note: Abnormal fingerprints or palmar creases, 3. Any individual who is a known balanced abnormal hair whorls or coloring of hair translocation carrier c. Careful inspection of newborns to identify a 4. Any individual who has an inborn error of child with a potential chromosomal disorder. metabolism or chromosomal disorder. Infants with multiple congenital anomalies, 5. A consanguineous (closely related) couple. born less than 35 weeks’ gestation, and whose 6. Any woman older than 35 years and any man parents have other children with chromosomal older than 55 years disorders need extremely close assessment. 7. Couples of ethnic backgrounds in which specific illnesses are known to occur. 3. Diagnostic Testing a. Karyotyping– a sample of peripheral venous Nursing Responsibilities: blood or a scraping of cells from the buccal 1. Explain to a couple what procedures they can membrane. expect to undergo. Cells are stained, placed under a microscope, 2. Explain how different genetic screening tests photographed and chromosomes are identified are done and when they are usually offered. size, shape, and stain, cut from the photograph, 3. Supporting a couple during the wait for test and arranged. results. - examines chromosomes to identify genteic disorders 4. Assisting couples in values clarifications, b. Maternal Serum Screening planning, and decision making based on test Alpha-fetoprotein (AFP) - is a glycoprotein results. produced by the fetal liver and reaches a peak in maternal serum between the 13th and 32nd wk. Genetic Disorders Assessment of pregnancy. 1. History done routinely at the 15th wk. of pregnancy a. Obtain information and document diseases in 30% has false-positive rate if the date of family members for a minimum of three conception is not well documented generations. - blood test measuring afp to check for potential birth defects b. Document the mother’s age (disorders c. Chorionic Villi Sampling– a diagnostic increase in incidence with age). technique that involves the retrieval and analysis c. Document whether the parents are of chorionic villi from the placenta for consanguineous or related to each other. chromosome or DNA analysis d. Documenting the family’s ethnic background may be done as early as wk. 5 of pregnancy, can reveal risks for certain disorders that occur more commonly done at 8 to 10 weeks. more commonly in some ethnic groups than Instruct a woman to report chills or fever others. suggestive of infection or symptoms of e. Extensive prenatal history of any affected threatened miscarriage (uterine contractions or person should be obtained to determine whether vaginal bleeding). environmental conditions could account for the Women with an Rh-negative blood type need condition. Rh immune globulin administration after the CHARLIZE M. TABUDLONG 4 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE procedure to guard against isoimmunization in - small camera to directly view the fetus and check for the fetus. abnormalities The cells removed in CVS are karyotyped or for DNA analysis to reveal whether the fetus has a genetic disorder. If a twin or multiple pregnancy is present, with two or more separate placentas, cells should be removed separately from each placenta. Because fraternal twins are derived from separate ova, one twin could have a chromosomal abnormality while the other does not. - takes a small tissue sample from placenta yo check for genetic issue d. Amniocentesis - withdrawal of amniotic fluid through the abdominal wall for analysis. done 14th- 16th wk. of pregnancy, fluid are karyotyped for chromosomal number and structure. - test amniotic fluid for genetic conditions by inserting a needle into the womb e. Percutaneous Umbilical Blood Sampling or Cordocentesis is the removal of blood from the fetal umbilical cord at about 17 wks. using an amniocentesis technique. allows analysis of blood components and more rapid karyotyping than is possible f. Fetal Imaging - used to assess a fetus for general size and structural disorders of the internal organs, spine and limbs a. Magnetic Resonance Imaging (MRI) b. Ultrasound g. Fetoscopy – the insertion of a fiberoptic fetoscope through a small incision in the abdomen into the uterus to visually inspect the fetus for gross abnormalities. h. Preimplantation Diagnosis– possible for In- Vitro Fertilization (IVF) provide genetic information extremely early in a pregnancy A fertilized ovum removed from the uterus by lavage before implantation and studied for DNA analysis The ovum would then be reinserted or not, depending on the findings and the parents’ wishes. CHARLIZE M. TABUDLONG 5 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE Wk. 1 – High Risk Pregnancy (Bleeding c. At least two medical doctors should reach the Disorders) decision and sign d. Elective abortion are unlawful and considered Bleeding Disorders a criminal acts. Vaginal bleeding during pregnancy is a deviation from the normal, may occur at any 2. Induced abortion point during pregnancy, and always Complications: frightening. a. Perforation of uterus, intestines, urinary bladder Any degree of bleeding, needs to be evaluated; b. Severe hemorrhage which may lead to a. Significant blood loss hypovolemic shock b. Hypovolemic shock c. Sepsis and its associated complications, c. Danger to the fetal blood supply Blood Loss -> Decreased intravascular volume - Spontaneous Miscarriage > Decreased venous return, decreased cardiac Abortion– termination of pregnancy before the output, and lowered BP -> blood loss > < blood in the age of viability heart > < blood heart Body compensating by: pumps > low bp Viable fetus– a fetus before 20-24 wks. a. increasing HR to circulate the decreased of gestation, and weighs at least 500 grams volume faster b. Vasoconstriction of peripheral vessels (to Types of Spontaneous Miscarriage save blood to vital organs) 1. Threatened spontaneous Miscarriage c. Increased RR and a feeling of apprehension 2. Imminent (inevitable) Miscarriage at body changes -> 3. Missed Miscarriage 4. Incomplete spontaneous Miscarriage Blood Loss -> Cold clammy skin, decreased 5. Complete spontaneous Miscarriage uterine perfusion (In the of continued blood loss, 6. Habitual 3 or more consecutive although the body shifts fluid from interstitial 7. Septic spaces into intravascular spaces, BP will continue to fall) -> Reduced renal, uterine, and Miscarriage– is a premature or immature birth brain perfusion -> Lethargy, coma, decreased Spontaneous Miscarriage- occurs in 15% - 30% renal output -> Renal failure -> Maternal and of all pregnancies and arises from natural Fetal death causes. a. Early miscarriage– occurs before week 16 of Bleeding Disorders Types: pregnancy b. Late miscarriage– occurs between week 16 1. Spontaneous Miscarriage – without medical and 20 of pregnancy or mechanical intervention - nalaglag ang bata nang hindi inaasahan; 3 months Common Causes of Spontaneous before Miscarriage 2. Induced abortion – with medical or 1. Abnormal Fetal Development mechanical intervention a. Teratogenic factors - Harmful substances (like - pinalaglag ang bata sa hospital o clinic; sadyang drugs or chemicals). pagpapalaglag ngunit legal b. Chromosomal aberration - Genetic problems that can affect growth. Legal Aspects: a. Only allowed for medical indications 2. Immunologic factors or rejection of the b. If continuation of pregnancy is risk to life of embryo through immune response the woman CHARLIZE M. TABUDLONG 6 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE 3. Implantation abnormalities - 50% Zygote Cause: Unknown– possibly never implant securely a. Chromosomal abnormalities Causes: b. Uterine abnormalities a. Inadequate endometrial formation - poor uterine lining Diagnostic Test b. Inappropriate site of implantation a. Blood exam– test for HCG hormones at the c. Failure of the corpus luteum to produce start of bleeding and again in 48 hrs. if the enough progesterone placenta is still intact, the level of HCG in the bloodstream should double in this time 4. Ingestion of alcohol at the time of conception b. Ultrasound– to evaluate the viability of the fetus (if the baby is developing normally) 5. Urinary tract infection– associated with c. Assess fetal heart sounds/heartbeat preterm birth. Management: 6. Systemic infection - diseases that affect the a. Avoidance of strenuous activity for 24-48 hrs. pregnancy b. Complete bed rest Cause: c. Coitus must be restricted for 2 wks. to prevent Rubella, Syphilis, Poliomyelitis Cytomegalovirus, infection and to avoid inducing further bleeding Toxoplasmosis d. Once bleeding stops, can gradually resume normal activities Spontaneous Miscarriage Assessment: 3. Imminent (Inevitable) Miscarriage 1. Vaginal spotting / bleeding - bleeding and cramping occur, and the cervix is starting to 2. Description of the bleeding open, meaning a miscarriage is likely to happen soon 3. Associated symptoms - cramping, sharp or If uterine contraction and cervical dull pain dilatation occur, the loss of the product 4. History of bleeding episode of conception cannot be halted. 5. Actions taken by the pregnant woman before and during the episode of bleeding Causes: 1. Unknown reasons Types of Miscarriage 2. Possible Poor placental attachment 1. Threatened Miscarriage - bleeding or cramping occurs, but the cervix is still closed and the pregnancy Symptoms: might still continue a. Cervical dilatation (Cervical os open) Early under 16 wks. - Cervical dilation is the opening of the cervix in Late -16-24 wks. preparation for childbirth. 50% - continue the pregnancy, 50% changes b. Uterine contractions from threatened to immanent or inevitable c. Cramping miscarriage d. Vaginal spotting to heavy bleeding Cervical os is closed and the product of Danger: Maternal Hemorrhage conception have not been expelled Diagnostic test: Symptoms: 1. Assessment of fetal heart sounds a. Vaginal bleeding– initially scant and bright red 2. Ultrasound b. Slight uterine cramping 2. Imminent (Inevitable) Miscarriage c. No cervical dilatation on vaginal examination (Close cervix) Management: d. Product of conception have not been expelled 1. Assessment CHARLIZE M. TABUDLONG 7 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE 2. Save any tissue fragments Management: - Save any tissue fragments to ensure all pregnancy 1. No Therapy (process is complete) products are removed. Analyze any abnormalities (e.g., 2. Advice the client to report heavy bleeding Hydatidiform mole). Record the number of pads used during this time. Incomplete Miscarriage If no fetal heart sounds detected and 4. Incomplete Miscarriage Ultrasound reveals empty uterus or nonviable - some pregnancy tissue remains in the uterus after a fetus reveal miscarriage, which may require medical treatment to 3. D&C or D & E - Remove part of the uterine lining remove. and contents by scraping. - the part of the fetus is expelled but the D & C (Dilation and curettage) – the dilatation of membranes or placenta are retained in the the cervix and surgical removal of part of the uterus lining of the uterus and the contents by scraping and scooping Cause D&E (Dilatation and evacuation (D&E)– Evacuate 1. Unknown the uterus to remove all pregnancy tissue. 2. Possible cchromosomal or uterine - the dilatation of the cervix and surgical abnormalities evacuation of the uterus to remove all High Risk: Hemorrhage and Uterine infection pregnancy tissue Symptoms: Health Teaching: After discharge 1. Vaginal spotting 1. Instruct client to assess their vaginal bleeding 2. Cramping by recording the number of pads used 3. Cervical dilatation (Open cervix) Note: Saturating more than one pad per hour is 4. Incomplete expulsion of uterine contents abnormally heavy bleeding Management: Complete Miscarriage 1. Dilatation & Curettage 4. Complete Miscarriage 2. Suction curettage - the pregnancy has been fully lost, and all pregnancy tisue has been expelled from the uterus 4. Incomplete Miscarriage - the entire products of conception are expelled spontaneously without any assistance (Fetus, Missed Miscarriage membranes, and placenta) 5. Missed Miscarriage - the fetus dies in the utero but is not expelled. (hindi niya alam na namatay na yung baby sa loob ng uterus) Cause - the fetus dies in utero but is not expelled. 1. Unknown (Early pregnancy failure) 2. Chromosomal abnormalities 3. Uterine abnormalities Cause: Unknown 1. Possible chromosomal abnormalities Symptoms: 2. Uterine abnormalities 1. Vaginal spotting 2. Cramping Diagnostic test: 3. Cervical dilatation a. Fundal height measurement - no increase in 4. Complete expulsion of uterine contents size during prenatal exam b. Ultrasound – establish embryo died 4 to 6 wks. Bleeding usually slows within 2 hours and before onset of miscarriage symptoms or failure ceases within a few days after passage of the of growth was noted products of conception c. Absence of fetal heart sounds CHARLIZE M. TABUDLONG 8 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE Symptoms: 5. Infections: Chorioamnionitis or uterine 1. Vaginal spotting infections (e.g., E. coli) can harm fertility. 2. Slight cramping 6. Autoimmune Disorders: Conditions where Management: the immune system attacks the body can 1. D & C (Dilatation and Curettage) interfere with fertility. 2. D & E (Dilatation and Evacuation) Immediate Assessment of Vaginal bleeding Management: during Pregnancy 3. Pregnancy over 14 wks. may induced labor a. Prostaglandin suppository or Misoprostol 1. Confirmation of Pregnancy - (+) Pregnancy (Cytotec) - introduced into the cervix to cause test dilatation 2. Pregnancy length– Age of Gestations b. Administration of Mifepristone - an oxytocin 3. Duration– how long did the bleeding episode stimulation which cause uterine contractions and last? birth. 4. Intensity– how much bleeding occurred If pregnancy is not actively terminated, 5. Description– blood mixed with amniotic fluid miscarriage occurs spontaneously within 2 wks. or mucus? 6. Frequency– Steady spotting? A single Danger: episode? Disseminated Intravascular Coagulation (DIC) – 7. Associated Symptoms– Cramping? Sharp may develop if the dead (and possibly toxic) pain? Dull pain? Has she ever had cervical fetus remains too long in utero surgery? 8. Action– what was she done to control the Recurrent Pregnancy Loss (Habitual bleeding Aborters) 9. Blood Type– Rh (-) patient need Rh 6. Recurrent Pregnancy Loss (“habitual aborters” Bleeding During Pregnancy Signs and - had three spontaneous miscarriage, laging nakukunan symptoms of Hypovolemic shocks - woman who had three spontaneous 1. Increase Pulse Rate miscarriages that occurred at the same 2. Decreased Blood Pressure gestational age. 3. Increased Respiratory Rate 4. Cold clammy skin Possible Causes: 5. Decreased urine output 1. Defective Sperm or Ova: Issues with the 6. Dizziness or decreased level of quality of sperm or eggs. consciousness 2. Endocrine Factors: 7. Decreased central venous pressure Lowered Protein-Bound Iodine (PBI): Indicates thyroid function issues. 1. Vital Signs & Fetal Monitoring: Assess vital Butanol-Extractable Iodine (BEI): Related to signs and continuously monitor the fetus. thyroid hormone availability. 2. IV Fluid Replacement: Administer Ringer’s Globulin-Bound Iodine (GBI): Another thyroid lactate for hydration. function marker. 3. Use Large-Gauge Angiocath: Insert a 16 or Poor Thyroid Function: Can lead to luteal 18 gauge for quick fluid and blood transfusions. phase defects affecting implantation. 4. Blood Tests: Obtain hemoglobin and 3. Uterine Anomalies: Such as a bicornuate hematocrit levels; secure blood samples for uterus, which can affect pregnancy. typing and cross-matching. 4. Blood Flow Resistance: Issues with blood flow in the uterine arteries can impact fertility. CHARLIZE M. TABUDLONG 9 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE 5. Oxygen Administration: Provide oxygen via  Parametritis: Infection of the tissue mask and monitor saturation levels with pulse surrounding the uterus. oximetry.  Peritonitis: Infection of the peritoneum (the 6. Positioning: Encourage the client to rest in a lining of the abdominal cavity). left side-lying position to prevent vena cava  Thrombophlebitis: Inflammation of a vein compression. due to a blood clot, often with infection. 7. Emotional Support: Offer information about  Septicemia: Systemic infection that can care and provide emotional support throughout spread throughout the body, often leading to the process. sepsis. Complications of Miscarriage: 1. Observe closely for fatal complication 1. Hemorrhage Management 2. Be certain that the client is familiar with danger signs of infection Nursing Interventions: a. Fever higher than 100.4◦ F (38.0◦ C)  Monitor Vital Signs: Check regularly to b. Abdominal pain or tenderness detect hypovolemic shock. c. Foul smelling vaginal discharge  Positioning: If there’s excessive vaginal 3. Advise the client not to use tampons bleeding, position the patient flat and massage the uterine fundus to promote Septic Abortion contraction. 2. Septic Abortion - when an abortion leads to infection  Pneumatic Antishock Garments: Apply these - an abortion that is complicated by infection to help maintain blood pressure. after a spontaneous miscarriage more frequently  Surgical Procedures: Perform D&C or in women who have tried to self-abort or were suction curettage to clear the uterus. aborted illegally using a nonsterile instrument  Medications: Administer oral methylergonovine maleate (Methergine) to Symptoms: help with uterine contractions. 1. Fever, crampy abdominal pain  Blood Transfusion: Consider transfusion to 2. Uterine tenderness upon palpation replace lost blood. 3. If left untreated, infection can lead to:  Clotting Factors: Directly replace fibrinogen (Toxic shock syndrome, Septicemia, Kidney or other clotting factors to improve failure, Death) coagulation.  Monitor Vaginal Bleeding: Keep track of Assessment and Treatment: amount, color, odor, and any large clots. 1. Laboratory Tests:  CBC: Complete blood count to check for 2. Infection Prevention infection and anemia. Infection Risk:  Serum Electrolytes: Assess electrolyte Escherichia coli: A common organism balance. responsible for infections after a miscarriage,  Serum Creatinine: Evaluate kidney function. often spreading from the rectum to the vagina. 2. Blood Type and Crossmatch: Prepare for potential transfusions. Caution: 3. Cultures: client to always wipe their perineal area from  Cervical, Vaginal, and Urine Cultures: front to back after voiding and after defecation to Identify any infections present. prevent spread of bacteria 4. Indwelling Urinary Catheter: Insert to  Endometritis: Infection of the inner lining of monitor hourly urine output and assess the uterus. kidney function. CHARLIZE M. TABUDLONG 10 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE 5. Antibiotic Administration: Common Site of Implantation:  Provide high-dose, broad-spectrum 1. Fallopian tube– 95% antibiotics (e.g., combination of Penicillin, a. Ampulla– 80% Gentamicin, and Clindamycin). b. Isthmus– 12% 6. Surgical Procedures: c. Interstitial or fimbria– 8%  D&C or D&E: Remove infected or necrotic 2. Cervix tissue from the uterus. 3. Ovary 7. Tetanus Prophylaxis: 4. Abdomen  Administer tetanus toxoid subcutaneously or 2. Ectopic Pregnancy tetanus immune globulin intramuscularly. Causes: Side Effects: 1. Adhesion of the Fallopian Tube: Can lead to 1. Infertility because of uterine scarring or fibrotic fertility issues. scarring of the fallopian tubes a. Previous Infection: 2. Infection by trying to Self abort– needs follow-  Chronic Salpingitis: Inflammation due to up counseling to assist the client to learn better infection. problem-solving methods for the future  Pelvic Inflammatory Disease (PID): Infection of the reproductive organs. Isoimunization b. Congenital Malformations: Abnormalities 3. Isoimmunization– (Rh incompatibility) present at birth. - person’s immune system make antibodies against their c. Scar Tissue: Formation of scar tissue from own blood type or that of their baby, often due to blood previous tubal surgery. differences between the mother and the fetus. d. Uterine Tumor: Growths in or around the - is a condition that happens when a pregnant uterus can cause adhesions. woman’s blood protein is incompatible with the baby’s, causing her immune system to react and 2. Congenital anomalies destroy the baby’s blood cells a. Webbing (fibrous bands) Predisposing factors: 7. Powerlessness or Anxiety 1. Cigarette Smoking 2. Intrauterine devices (IUDs) - may slow the Management: transport of the zygote 1. Assess a woman’s adjustment to a 3. Previous ectopic pregnancy (10% to 20% spontaneous miscarriage. because of Salpingitis leaves a. Sadness and grief over the loss scarring usually bilateral). b. Feeling that a woman has lost control of her life is to be expected. Assessment: 2. Assess a partner’s feelings or that person’s 1. No unusual symptoms at the time of grief over the pregnancy loss implantation 2. No menstrual flow occurs. Primary causes of Bleeding during 3. Nausea and vomiting of early pregnancy Pregnancy 4. Pregnancy test positive for hCG (+) First and Second Trimester 2. Ectopic Pregnancy 1. Miscarriage 2. Ectopic Pregnancy Diagnostic Test: 1. Pregnancy test– HCG (+) 2. Ectopic pregnancy– implantation occurred 2. Ultrasound– 6 -12 wks. of pregnancy outside the uterine cavity/uterus - mostly in fallopian tube CHARLIZE M. TABUDLONG 11 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE (Transvaginal ultrasound) demonstrate ruptured 6. Diagnostic Procedures: tube and blood collecting in the peritoneum  Culdoscopy: Examines the cervix, vagina, 3. Magnetic Resonance Imaging (MRI) -if not and vulva for disease. revealed by an Ultrasound  Laparoscopy: A surgical procedure using a fiber-optic instrument to view abdominal Clinical Manifestations: organs and perform interventions. 1. Sharp, stabbing pain in one of the lower abdominal quadrants at the time of rupture Purpose: (Unilateral) 1. To ligate the bleeding vessels 2. Dark red or brown vaginal bleeding 2. To remove or re-pair the damaged fallopian 3. Blood loss– hypotension, lightheadedness, tube. signs of severe shock 4. Leukocytosis Surgical Management: 5. Rigid abdomen from peritoneal irritation 9. Laparotomy– Salpingectomy– is a surgical 6. Cullen sign– bluish-tinged discoloration incision into the abdominal cavity to remove one around the umbilicus due to hemoperitoneum (unilateral) or both 7. Pain in the shoulder caused by irritation ofthe (bilateral) fallopian tubes phrenic nerve 10. Antibiotic 8. Dull vaginal and abdominal pain 9. Tender mass palpable in cul-de-sac on 10. Administration of (RhIG) RoGAM to Rh (-) vaginal examinations negative mothers Nursing Care: Therapeutic Management: 1. Vital signs 1. Medications: 2. Administer IV fluids  Methotrexate: 3. Monitor for vaginal bleeding  Administered orally; a folic acid antagonist 4. Monitor I & O that destroys fast-growing cells.  Follow with Leucovorin to reduce side effects.  Treatment continues until a negative hCG titer is achieved. 2. Imaging:  Hysterosalpingogram or Ultrasound:  Conducted after chemotherapy to check if the fallopian tube is fully patent. 3. Mifepristone:  Induces sloughing of the tubal implantation site. 4. Laboratory Tests:  Hemoglobin Level: Check for anemia.  Blood Typing and Cross-Matching: Prepare for possible transfusion. 5. Fluid Management:  Intravenous Fluids: Administered via a large- gauge catheter to restore intravascular volume. CHARLIZE M. TABUDLONG 12 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE CU 1 Bleeding Disorders (2nd and 3rd 4. Blood Group A women who marry Blood Trimester) Group O 5. Incidence of GTD have increase risk of 2nd h- Primary Causes of Bleeding During mole pregnancy Pregnancy Diagnostic Test: Second Trimester 1. Ultrasound- show dense growth (snowflake 1. Gestational Trophoblastic Disease pattern) 2. Premature Cervical Dilatation 2. Chromosomes Analysis a. Maternal Serum Screening Third Trimester b. Chorionic Villi Sampling 1. Placenta Previa 2. Abruptio Placenta Types of Gestational Trophoblastic disease 3. Preterm labor 1. Complete Mole – all trophoblastic villi swell and become cystic. Gestational Trophoblastic ▪ if embryo forms: Disease (H- mole) Dies early at 1-2 mm. in size with no fetal Trophoblast– are cells forming the outer layer of blood present in the villi a blastocyst Types of Gestational Trophoblastic Disease Function: 1. Complete Mole ▪ Provide nutrients to the embryo and develop - Rare; usually does not develop. into a large part of the placenta. ▪ play an important role in embryonic ▪ if embryo forms: implantation and interaction with the ▪ Chromosomal Analysis: Paternal origin decidualized maternal uterus. a. Contributed only by the Father b. Empty ovum was fertilized Fertilization c. Chromosome was duplicated Blastocyst– an embryo that is developed after - All chromosomes come from the father. - An empty egg is fertilized, leading to duplication of paternal fertilization chromosomes. - early stage of embryo that forms after fertilization 2. Partial mole – some of the trophoblastic villi Gestational Trophoblastic Disease (H- mole) form normally. Abnormal proliferation/growth and a. Syncytio trophoblastic layer appears swollen degeneration of the trophoblastic villi, as the and misshapen. cells degenerate they become filled and appear b. Embryo may grow for about 9 wks. as clear fluid-filled, grape- sized vesicles c. Partial mole rarely lead to Choriocarcinoma The incidence of Gestational Trophoblastic d. Partial mole has 69 Chromosomes disease is approximately 1 in every 1500 (69 XX or 69 XY) Paternal and Maternal pregnancies There are three chromosomes instead of two for every pair The embryo fails to develop due to abnormal One set supplied by an ovum fertilized Trophoblast cells produced. by two sperm. An ovum fertilized by one sperm in which Associated with Choriocarcinoma High risk : meiosis did not occur. 1. Low protein intake - 69 chromosomes (69 XX or 69 XY). 2. Older than 35 y/o - One set from an egg fertilized by two sperm or from an 3. Asian egg that didn't undergo meiosis. CHARLIZE M. TABUDLONG 13 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE Assessment: Diagnostic Test: 1. Uterine Overgrowth: Early Ultrasound before sign and symptoms  12 Weeks AOG: Fundus is above the occur symphysis pubis.  20-24 Weeks AOG: Fundus reaches the Sign and Symptoms: level of the umbilicus. 1. Painless cervical dilatation 2. hCG Levels: 2. Bloody show (Pink-stained vaginal discharge)  Serum and Urine Tests: hCG levels can be 3. Increased pelvic pressure as high as 1-2 million IU, compared to a 4. Premature rupture of the membrane and normal pregnancy level of about 400,000 IU. discharge of amniotic fluid. 3. Symptoms:  Nausea and Vomiting: Often due to elevated Management: hCG levels. 1. Cervical Cerclage - A surgical procedure 4. Vaginal Discharge: where purse-string sutures are placed in the  Dark brown spotting with clear fluid-filled cervix to prevent premature dilation and support vesicles. the pregnancy. 5. Ultrasound Findings:  Success Rate: 80% - 90% effective in  No fetal growth or fetal heart sounds preventing miscarriage or preterm birth. detected. Types of Cerclage Therapeutic Management a. McDonald Procedure: 1. Suction curettage– to evacuate the abnormal  Technique: Nylon sutures are placed Trophoblast cells (helps to process blood clotting) horizontally and vertically across the cervix.  Timing: Typically performed between 12-14 Following mole extraction: weeks of gestation. 1. Pelvic examination 2. Serum test– HCG level analyzed b. Shirodkar - A type of cervical cerclage where ▪ every 2 wks. until levels are normal sterile tape is placed to support the cervix. ▪ every 4 wks. for 6 - 12 months Technique: 3. Prophylactic Methotrexate– drug of choice for  The tape is threaded in a purse-string choriocarcinoma manner beneath the subcutaneous layer of 4. Oral estrogen/progesterone contraceptives the cervix. 5. Dactinomycin– can be added if metastasis  Purpose: Provides additional support to occur prevent cervical insufficiency during pregnancy. Cervical Insufficiency (Premature Cervical Dilatation) Management: Note: Suture are removed 37th to 38th wks. of Incompetent Cervix pregnancy Incompetent Cervix– a cervix that dilates prematurely and cannot retain a fetus until term. After cerclage surgery: occur at approximately week 20 of pregnancy. 1. Bed rest in slight or modified Trendelenburg associated with position. 1. Increased maternal age 2. Avoid coitus and limit activities Cervical 2. Congenital structural defects Cerclage 3. Cervical trauma CHARLIZE M. TABUDLONG 14 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE Contraindications 1. Low-Lying Placenta: 1. Active labor  Definition: Implantation occurs in the lower 2. Premature rupture of membrane portion of the uterus, but not covering the 3. Abruptio placenta cervix. 4. Active vaginal bleeding 2. Partial Placenta Previa: 5. Chorioamnionitis – inflammation of fetal  Definition: The placenta partially occludes membrane due to bacterial infection. the cervical os, obstructing part of the opening. Primary causes of Bleeding during Third 3. Total Placenta Previa: Trimester of Pregnancy  Definition: The placenta completely obstructs the cervical os, preventing any Placenta Previa vaginal delivery. Is a condition of pregnancy in which placenta 4. Marginal Implantation: implanted abnormally in the uterus  Definition: The edge of the placenta assessed through routine Sonograms approaches the cervical os but does not cover it. Causes: 1. Increased Parity Management: Placenta Previa 2. Advanced maternal age 1. Bed Rest: Side-lying position; no bathroom 3. Past cesarean births privileges. 4. Past uterine curettage 2. Monitor Blood Loss: Keep a perineal pad 5. Multiple gestation count. 6. Male fetus are all associated with 3. Kleihauer-Betke Test: Detect fetal RBCs in maternal circulation for Rh (-) mothers. Diagnostic Test: Ultrasound 4. Vital Signs: Establish baseline; check BP every 5-15 minutes for hypovolemic shock. 5. No Pelvic or Rectal Exams: May trigger Sign and Symptoms: severe hemorrhage. 1. Sudden onset of painless uterine bleeding, 6. Lab Tests: Check for clotting disorders. (bright-red discharges)– begins when the lower 7. Monitor Urine Output: Check hourly. uterine segment starts to differentiate from the 8. IV Fluids: Administer via a large-gauge upper segment late in pregnancy (wk. 30) catheter for potential blood replacement. 2. Bleeding may be profuse or scanty and 9. Fetal Monitoring: Attach equipment to record spotting continuous. fetal heart sounds (FHS) and contractions. 10. Betamethasone: For lung maturity if fetus is Fetal Implications: under 34 weeks. a. Congenital fetal anomalies 11. Delivery Method: Plan for cesarean birth. b. Fetal restricted growth Abruptio Placenta Four Degrees of Placenta Previa premature separation of a normally implanted 1. Low-lying placenta placenta either partial, marginal or complete that 2. Partial Placenta Previa can lead to extensive bleeding. 3. Total Placenta Previa - Premature separation of a normally implanted placenta, 4. Marginal Implantation which can be partial, marginal, or complete. most frequent cause of perinatal death. separation occurs late in pregnancy, even as late as during the 1st and 2nd stage of labor. CHARLIZE M. TABUDLONG 15 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE Risks: Can cause extensive bleeding and is a leading cause of perinatal death. 2. Marginal bleeding type– the type that manifest Timing: Separation can occur late in pregnancy, including during the first and second stages of labor. with external hemorrhage. Vaginal bleeding is dark red “old” blood Causes: Unknown 3. Total bleeding type - denotes the degree of Predisposing factors: placental detachment 1. High parity Severe hemorrhage, external or internal that 2. Advanced maternal age fetal outlook is poor. 3. Short umbilical cord 4. Chronic Hypertensive disease Degrees of Separation Grade Criteria 5. Hypertension of pregnancy (PIH) 1. Grade 0– no symptoms of separation, 6. Direct trauma placenta is examined after birth and shows 7. Cocaine or cigarette use (Vasoconstriction) recent clot on maternal surface. 8. Thrombosis formation - Thrombosis is the 2. Grade 1– minimal separation, cause vaginal formation of a blood clot within a blood vessel, which can bleeding, changes in maternal VS, no obstruct blood flow. occurrence of fetal distress 9. Infection (Chorioamnionitis)– infection of the and hemorrhagic shock. fetal membrane 3. Grade 2 – moderate separation, there is evidence of fetal distress, uterus is tense and Signs and Symptoms: painful on palpation. 1. Sharp, stabbing abdominal pain 4. Grade 3 – extreme separation, without 2. Uterine tenderness during palpation. immediate interventions, maternal hypovolemic 3. Heavy vaginal bleeding accompanies shock and fetal death will result. premature separation of the placenta 4. Signs of hypovolemic shock Management: Hypovolemic shock – the circulatory dysfunction 1. Positioning: Keep the client in a left lateral due to bleeding. position; reposition at intervals. Hypovolemic shock – reduction of 2. Monitoring: Check fetal heart sounds and intravascular blood volume that could lead to record maternal vital signs every 5-15 minutes. tissue anoxia. 3. IV Fluids & Oxygen Therapy: Administer to a. Tachycardia limit fetal anoxia. b. Hypotension 4. Baseline Fibrinogen: Measure if bleeding is c. Shallow respiration extensive. d. Cyanosis 5. No Examinations: Avoid abdominal, vaginal, 5. Couvelaire uterus– the uterus is purplish in or pelvic exams. color, board-like and rigid as bleeding 6. Assess Bleeding: Monitor the amount and progresses. nature of any bleeding. Types of Abruptio Placenta: Cause: Unknown 1. Concealed (Central, Convert) ▪ Associated with infection of the membranes 2. Marginal bleeding type (Chorioamnionitis) 3. Total bleeding type Complications: 1. Concealed (Central, Convert)– the placenta 1. Uterine and fetal infection detaches from the center and blood 2. Increased pressure on the umbilical cord accumulates behind the placenta. CHARLIZE M. TABUDLONG 16 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE 3. Cord prolapse– extension of the cord out of 3. Cervical dilatation– greater than 1 cm the uterine cavity into the vagina. 4. Potter- like syndrome– distorted facial Cause: Unclear features 5. Pulmonary Hypoplasia– incomplete Risk factors: Maternal factors development of the lungs resulting in 1. Excessive fatigue abnormally low number or size of alveoli 2. Maternal infections (UTI, Chorioamnionitis) 3. Dehydration Sign and Symptoms: 4. Large fetal size 1. Fluid Loss: Sudden gush of clear fluid from 6. Chronic illness or disease (cardiovascular, the vagina. diabetes, renal) 2. Nitrazine Paper Test: 7. Extreme emotional stress  Amniotic Fluid: Alkaline reaction (turns blue). 8. Intimate partner violence and trauma.  Urine: Acidic reaction (remains yellow). 3. Positive Ferming Test: Signs and symptoms  Swab and dry on a slide; high-estrogen fluid 1. Persistent, dull, and low backache. appears on microscopic examination 2. Vaginal spotting (indicates amniotic fluid). 3. Feeling of pelvic pressure or abdominal 4. Alpha-Fetoprotein (AFP): High levels present tightening in the vagina. 4. Menstrual-like cramping 5. Ultrasound: Assess amniotic fluid index. 5. Increased vaginal discharged, uterine 6. Cultures: Test for Neisseria gonorrhea, Group contractions, and Intestinal cramping. B streptococcus, and chlamydia. 8. Pain, discomfort or pressure in the vulva or 7. Blood Tests: thighs  Check WBC count and C-reactive protein (increased levels indicate membrane Therapeutic Management: Preterm Labor rupture). 1. Hospitalization: Admit for close monitoring. Note: Avoid vaginal exam due to risk of 2. Bed Rest: Maintain a left lateral position. infections 3. Monitoring: Track fetal heart rate (FHR) and uterine contractions. Management: 4. Cultures: Perform vaginal and cervical 1. Strict bed rest cultures, and obtain a clean-catch urine 2. Administration of Corticosteroid– to hasten sample. fetal lung maturity. 5. Hydration: Ensure adequate hydration (oral 3. Prophylactic administration of broad-spectrum and parenteral). antibiotics 6. Medications: Administer tocolytics and 4. Administration of Tocolytic agent if labor corticosteroids. begins. 1. Tocolytic Agents: Used to stop premature labor by relaxing the uterus. Preterm Labor a. Terbutaline: Preterm Labor- occur before the end of 37 wks. Administration: IV, oral, or subcutaneous. of gestation. Side Effects: Fetal tachycardia, decreased blood pressure, chest pain, Criteria of Preterm Labor: dizziness. 1. Contractions - 4 in 20 mins or 8 in 60 mins Antidote: Propranolol (Inderal). and progressive change in cervix. 2. Cervical effacement - 80% or greater CHARLIZE M. TABUDLONG 17 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE b. Magnesium Sulfate: 2. IVF (3000 ml. RL with added vit. B) Function: Inhibits labor by stopping 3. Antiemetic (metoclopramide (Reglan) premature contractions. 4. Measure I & O Side Effects: Respiratory depression, 5. If no vomiting for 24 hrs. clear fluid decreased reflexes. 6. Dry toast, crackers, or cereal every 2-3 hrs., Antidote: Calcium gluconate. gradually to soft diet then normal diet Corticosteroids: Enhance fetal lung maturity. 7. TPN if vomiting returns Examples: Betamethasone, Dexamethasone. Timing: Administered between 24-34 weeks of gestation, especially before 34 weeks if birth is imminent. Management: Preterm labor Labor that cannot be Halted: (Inevitable) Criteria: Cervical dilatation 3-4 cm dilated, 50% effacement ruptured fetal membrane Method of delivery: Cesarean Section a. To reduce pressure on fetal head b. To reduce subdural or interventricular hemorrhage Gestational Conditions Hyperemesis Gravidarum Hyperemesis gravidarum (Pernicious or Persistent vomiting) - is nausea and vomiting of pregnancy that is prolonged past wk. 12 of pregnancy occurs at an incidence of 1 in 200 to 300 women Cause: 1. Unknown 2. Increase thyroid function 3. Associated by Helicobacter pylori Symptoms: a. Vomiting b. Fatigue c. Dehydration d. Ketonuria e. Weight loss f. Elevated hematocrit concentration Management: Hospitalization for 24 hrs. 1. NPO for 24 hrs. CHARLIZE M. TABUDLONG 18 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE Gestational condition Pregnancy Induced ↓ Hypertension (Gestational Hypertension) Vasoconstriction and Increase Blood Pressure - is a health issue that develops during pregnancy such as ↓ gestational diabetes or preeclampsia Reduces blood supply to organs - if the mother having problems with blood flow it can affect the baby ↓ (Kidney, pancreas, liver, brain, Placenta) Three factors that influence Blood pressure: ↓ 1. Cardiac Output– the amount of blood the Result in signs and symptoms - Vascular spasms during pregnancy, caused by heart pumps through the circulatory system in a increased blood flow, can damage artery linings, narrow minute. the vessels, and raise blood pressure. This reduces blood 2. Blood volume– the total amount of circulatory supply to important organs like the kidneys, pancreas, blood in the body. liver, brain, and placenta, leading to symptoms. 3. Resistance– anything that works against the blood flow to the artery. Pathophysiologic Events a. Flexibility Reduces Blood supply to organs b. Diameter Implications: c. Blood viscosity 1. Kidney - vasoconstriction leads to ↓ blood flow leading to Pregnancy Induced Hypertension (PIH) ↑ Renin, Angiotensin and Aldosterone secretion  Definition: A condition characterized by ▪ substances that increases vasoconstriction and vasospasm in both small and large arteries blood volume, further ↑ blood pressure causes during pregnancy. damage to the arterial walls Reduces Blood  Onset: Begins around the 20th week of supply to organs: pregnancy.  Incidence: Occurs in 5% to 7% of Implications: pregnancies. 1. Kidney - ↓ blood supply lead to :  Postpartum: Symptoms regress after a. Decreased urine output and Proteinuria delivery. b. Sodium retention (Edema)  Also Known As: "Toxemia of Pregnancy." 2. Pancreas– ischemia (insufficient blood flow to a  Mechanism: The body produces "toxins" in tissue or organ) in the pancreas result in: response to foreign proteins from the a. Epigastric pain growing fetus, leading to typical symptoms. b. Elevated amylase 3. Retina– spasm of the arteries in the retina ▪ Cause– Unknown leads to vision changes ▪ correlated with Antiphospholipid antibodies in a. Retinal hemorrhage maternal blood b. Blindness ▪ occurs when the immune system mistakenly 4. Placenta– poor perfusion reduces attacks the normal protein in fetal nutrients and oxygen supply. the blood causes blood clots formation Pathophysiologic Events in Gestational Hypertension Pathophysiology of Gestational 1. Vasoconstriction and arteriolar vasospasm. Hypertension 2. Decrease in circulating volume Vascular Spasm– occur due to increased 3. Activation of the coagulation system (helps cardiac output required by pregnancy blood clot) - vasospasm is when blood vessels suddenly tighten, ↓ reducing blood flow, and potentially causing pain or tissue Injuries to the endothelial cells of the arteries damage CHARLIZE M. TABUDLONG 19 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE Pregnancy Induced Hypertension 2. Mild Preeclampsia Predisposing factors: - BP 170/105 mmhg; protein in urine, mild swelling, 1. Multiple pregnancy usually in the hands and feet 2. Primipara younger than 20 y/o or older than - Hypertension, Proteinuria and Edema. 40 y/o a. Blood Pressure - is 140/90 mmhg 3. Low socioeconomic backgrounds ▪ Systolic BP– elevates to 30 mmhg 4. Five or more pregnancies ▪ Diastolic BP– elevates to 15 mmhg above pre 5. Client with Polyhydramnios – over production pregnancy level of amniotic fluid ▪ BP is taken on two occasions at least 6 hrs. 6. Diseases (heart disease, diabetes with vessel apart. or renal involvement, hypertension ) b. Mild edema in upper extremities or face– due to sodium retention lowered glomerular filtration Maternal Implication: rate 1. Increase blood pressure c. Weight gain over 2 lb./ wk. in second trimester 2. Decrease perfusion and 1 lb./ wk. in 3rd trimester 3. Ischemia of various organs (kidney, d. Proteinuria of 1+ to 2+ on a random sample. pancreas, liver, brain and Placenta) Pathophysiologic Events in Pregnancy Induced Nursing Interventions: Hypertension 1. Monitor Antiplatelet Therapy - low- dose aspirin may prevent or delay the development of Fetal Implication: Preeclampsia (Aspirin 81 mg.) 1. Intrauterine growth restriction 2. Provide emotional support (potential serious 2. Low birth weight of symptoms) 3. Prematurity 4. IUFD Severe Preeclampsia 1. Severe Preeclampsia - BP 190/125 mmhg; mark proteinuria, severe edema, and Type of Pregnancy Induced Hypertension sypmtoms like visual disturbances and severe headaches. 1. Gestational Hypertension - risk for Eclampsia 2. Mild Preeclampsia 3. Severe Preeclampsia Signs and Symptoms: 4. Eclampsia 1. Blood pressure is 160/110 mmHg. Systolic increase greater than 30 mm hg Diastolic pressure greater than 15 mm hg. Type of Hypertension: 2. Proteinuria 3+ to 4+ on a random urine 1. Gestational Hypertension sample. - this is high blood pressure during pregnancy w/o any signs of kidney problems (like protein in urine) or swelling 3. Cerebral or visual disturbances (edema) (Headache, blurred vision) Blood pressure is 140/90 mmhg. 4. Nausea or vomiting No proteinuria or edema 5. Pulmonary edema (shortness of breath) Blood pressure returns to normal after birth. 6. Extensive peripheral edema Nursing Intervention: Assessment: Edema 1. BP monitoring 0 + - No pitting edema 2. Low salt diet 1 + - if the tissue can be indented slightly and 3. No drug therapy disappear rapidly 2 + - moderate indentation CHARLIZE M. TABUDLONG 20 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE 3 + - moderately severe edema - deep a) Hydralazine, Labetalol, Nifedipine: Lower indentation hypertension without affecting placental 4 + - severe pitting edema circulation. Monitor pulse and BP before and after administration. 7. Severe Preeclampsia b) Diastolic pressure should remain above 80- 8. Epigastric pain 90 mmHg to ensure adequate placental 9. Oliguria- 500 ml. or less in 24 hrs. perfusion. altered renal function test  Magnesium Sulfate: elevated serum creatinine more than 1.2 mg,/dl a) Anticonvulsant of choice to prevent 10. Hepatic dysfunction eclampsia. 11. Thrombocytopenia b) Administer IV with a loading dose (2-6 grams in 250 ml over 20 min), then Nursing Interventions: continuous infusion. 1. Supportive Care: c) Effects last 30-60 minutes.  Bed Rest: Left recumbent position for better blood flow to the uterus. Symptoms of overdose from Magnesium  Environment: sulfate: a) Private room. 1. Decrease urine output b) Darken the room to reduce light exposure 2. Depressed respiration (can trigger seizures). 3. Reduced consciousness c) Restrict visitors. 4. Decrease deep tendon reflex d) Raise side rails to prevent injury during Adverse Effects: seizures. Flushing, thirst, with toxicity, absence of DTR, 2. Nutritional Support: respiratory depression, cardiac  Moderate to high protein diet, moderate arrhythmias, cardiac arrest, decreased urine sodium intake. output 3. Maternal Monitoring:  Blood Pressure: Monitor every 4 hours for 1. Urine Output: increases.  Severe oliguria: 30 ml/hr, specific gravity function, BUN, creatinine, and fibrin to ≤1.010. assess kidney and liver function. 2. Serum Magnesium:  Blood Typing: Cross-match due to risk of  Keep below 75 mEq/L. abruptio placenta. 3. Respiratory Rate:  Daily Weights: Check for fluid retention.  Target: 12 bpm.  Urinary Output: Indwelling catheter 4. Neurological Checks: with >600 ml/24 hrs. (30 ml/hr.); check  Minimal ankle clonus, deep tendon reflexes protein-creatinine ratio (preeclampsia: >0.5 (DTR) present. or 3-4 g/24 hrs.). 5. Observation: 4. Fetal Monitoring:  Watch for CNS depression and hypotonia in  Doppler Auscultation: Every 4 hours. newborns; check for maternal calcium deficit.  Nonstress Test/Biophysical Profile: Assess 6. Antidote: uteroplacental sufficiency.  Calcium gluconate (1 g IV, 10 ml of 10%  Oxygen for Mother: Maintain adequate fetal solution) available at bedside for magnesium oxygenation. sulfate toxicity. 5. Medications:  Antihypertensives: CHARLIZE M. TABUDLONG 21 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE 7. Fetal Monitoring: Nursing Interventions:  Monitor fetal heart rate (FHR) and watch for. If pregnancy is greater than 34 wks. late decelerations during contractions. Labor should be induced or a Cesarean birth performed Eliciting A Patellar Reflex And Ankle Clonus If pregnancy is less than 34 wks.– intervention Patellar Reflex/Knee-jerk reflex to alleviate symptoms and allow to continue 1. Place the woman in a supine position, ask her pregnancy to bend her knee slightly. 2. Place your hand under her knee to support Eclampsia the leg. 4. Eclampsia 3. Locate the patellar tendon in the midline just - this is a serious condition where high blood pressure below the kneecap. causes seizures or coma, often due to swelling in the brain. 4. Strike it firmly and quickly with a reflex - either seizure or coma accompanied by signs hammer or the side of your hand. and symptoms of preeclampsia. If the leg and foot move, a patellar reflex is happens late in pregnancy but can happen up present. - used reflex hammer to 48 hrs. after childbirth Ineffective tissue perfusion (vasoconstriction of The reflex is scored as: blood vessel) 0 - No response; hypoactive; abnormal Deficient fluid volume related to fluid loss to 1+ - Somewhat diminished response but not subcutaneous tissue abnormal Risk of fetal injury ( reduced placental 2+ - Average response perfusion) 3+ - Brisker than average but not abnormal Social isolation (prescribed bed rest) 4+ - Hyperactive; very brisk; abnormal Symptoms: Ankle Clonus 1. BP ↑, temperature ↑(103◦F- 104◦F (39◦C- Definition: Ankle clonus is an involuntary, 40◦C) rhythmic muscle contraction resulting from a 2. Blurring of vision or severe headache permanent lesion in descending motor neurons. (increase cerebral edema) It can occur in various locations, including the 3. Severe epigastric pain ankle, patella, triceps, wrist, and biceps. 4. Decrease urinary output (< 30 ml./hr.) 5. Hyperactive reflexes Assessment Steps 1. Eliciting Ankle Clonus: Tonic - Clonic Seizures– an eclamptic seizures a) Dorsiflex the woman’s foot three times that occurs in stages. quickly. b) Release your hand and observe the foot. Stage I - Tonic Phase last approximately 20 c) Interpretation: secs. d) No further movement: Ankle clonus is all the muscles of the body contract absent. e) Continued involuntary movement: Ankle Symptoms: clonus is present. 1. Back arches, arms, and legs stiffen 2. Rating Clonus: 2. Jaw closes (may bite their tongue) a) Mild: 2 movements. 3. Respiration halt (thoracic muscles contract) b) Moderate: 3–5 movements. 4. Slightly cyanotic (cessation of respiration) c) Severe: Over 6 movements. CHARLIZE M. TABUDLONG 22 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE Nursing responsibilities during Seizures Attack Prepared method of birth: - Safety is also a top priority Labor can be induced after an eclamptic seizures Convulsive movements– may be strong that the Cesarean birth– if far from full term and the client can throw herself out of bed. Promote cervix is resistant to the induction process client's safety ▪ Keep the bed in a low position, keep siderails Nursing intervention during Postpartum period (6 up and padded wks. After childbirth) ▪ Do not insert a tongue depressor in the mouth 1. MonitorBP in post partum period and health for it may cause more harm care visits ▪ Do not apply restraints to prevent trauma 2. Alert for preeclampsia to detect residual (Bone fractures) hypertension Primary care for Tonic- Clonic Seizures Nursing responsibilities: 1. Maintain patent airway to prevent aspiration Turn onto side to allow secretions to drain in their mouth. 2. MagSo4 or diazepam may be administered by IV as emergency measures 3. Assess O2 saturation via pulse oximeter 4. Administer O2 by face mask as needed to protect fetal oxygenation 5. Apply external fetal monitor to assess FHR 6. Assess uterine contractions and check for vaginal bleeding to detect placental separation Stage II Clonic Stage– last up to 1 min. 1. Bladder, bowel muscles contract and relax - incontinence of urine and feces 2. Remain cyanotic - breathing is not entirely effective Stage III Postictal Stage– unconscious and cannot be roused except for painful stimuli for 1 - 4 hrs. Nursing responsibilities: 1. Extremely closed observation and assess for uterine contraction 2. Keep the client on her side to drain secretion from their mouth 3. NPO 4. Be certain conversation Is limited 5. Continue to check for vaginal bleeding every 15 mins. CHARLIZE M. TABUDLONG 23 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE Wk. 2 Gravido- cardiovascular Disorder Rheumatic fever - inflammatory disease that can develop after a strep Cardiovascular Disorders during Pregnancy throat infection. it can affect the heart, joints, and etc. IF NOT TREATED, IT CAN DAMAGE THE HEART Causes: A- beta hemolytic Streptococcus Gravido-cardiac - heart problems that happen during pregnancy. these ▪ Inflammation leads to fibrin deposits on the conditions can be risky for both the mother and the baby, endocardium and valves (Mitral valve) so they need close monitoring and special care. Hypertension was once a major threat to ▪ Long term effects: pregnancy and complicates 1% of all Myocarditis, endocarditis, pericarditis, heart pregnancies failure Even with the decreased cases cardiovascular diseases remains a concern leading to serious 2. Congenital anomalies: complications a. Atrial Septal Defect ▪ Blood volume and cardiac output increased b. Aortic dilatation approximately 30% and up to 50% during c. Uncorrected coarctation of the aorta pregnancy. ▪ Half of the increase, happens by 8 wks. and is Classification of Heart Disease maximized by mid pregnancy) ▪ 28 - 32 weeks - dangerous time for pregnant Class 1 (mild, no limitations) woman with cardiac disease just Description: No limitation of physical activity, after blood volume peaks Asymptomatic with normal activity Uncompromised The most common Cardiovascular Disorders Ordinary physical activity causes no discomfort that causes difficulty during pregnancy: No symptoms of cardiac insufficiency 1. Valve Damage: No anginal pain  Caused by rheumatic fever or Kawasaki disease. Class II (slight limitations) 2. Congenital Anomalies: Description: Mild limitation of physical activity,  Includes atrial septal defect and uncorrected Symptoms with normal physical activity coarctation of the aorta. Slightly compromised 3. Coronary Artery Disease: Ordinary physical activity causes excessive  Affects blood flow to the heart. fatigue, palpitation, dyspnea, or anginal pain 4. Varicosities:  Enlarged veins, often in the legs. Class III (moderate limitations) Description: Marked limitation of physical activity, The most common Cardiovascular Disorders Symptoms with less than normal activity, that causes difficulty during pregnancy: comfortable at rest 1. Valve damage Markedly compromised - tricuspid, pulmonary, mitral, and aortic valve During less than ordinary activity patient experience excessive fatigue, palpitation, Causes: dyspnea, or anginal pain a. Damage to one or more heart valves that remains after an episode of acute Rheumatic Class IV (severe limitations) fever. (Kawasaki disease) Description: Severe limitation of physical activity, b. Rheumatic fever - an acute systemic Symptoms at rest inflammatory disease of childhood, develops Severely compromised after infection of upper respiratory tract. CHARLIZE M. TABUDLONG 24 BSN MATERNAL AND CHILD HEALTH NURSING NCMA 219 LECTURE Patient is unable to carry out any physical - causing blood to flow backward into the left atrium when activity without experiencing discomfort the heart pumps Even at rest, symptoms of cardiac insufficiency c. Aortic coarctation– it is the narrowing or anginal pain are present of the aorta. - hardder for blood to flow through the body - mitral valve condition A Pregnant Patient with Cardiac Disease Symptoms: 1. Shortness of Breath: Due to fluid in the lungs from left-sided heart failure. 2. Cough: Blood-streaked sputum from pulmonary congestion. 3. Nocturnal Dyspnea: Paroxysmal nocturnal dyspnea indicates worsening heart function at night. 4. Fatigue: Weakness and dizziness from poor blood circulation. 5. Orthopnea: Difficulty breathing when lying flat due to lung fluid. 6. Increased Heart Rate: Compensation for A Pregnant Patient with Left-Sided Heart reduced heart efficiency. Failure 7. Thrombus Formation: Stagnant blood flow can lead to clots. 8. Pulmonary Edema: Result of high pressure in pulmonary circulation from left-sided heart issues. Management: Left ventricle cannot move the volume of blood 1. Antihypertensives: Medications to lower forward that it has received by the left atrium blood pressure. from the pulmonary circulation 2. Diuretics: Help reduce fluid retention and blood pressure. - help rmeove excess fluid to Causes: reduce sweling and lung fluid 1. Mitral Stenosis 3. Anticoagulants: 2. Mitral Insufficiency a) Heparin: Used in early pregnancy. safe in early pregnancy 3. Aortic Coarctation b) Coumadin (Warfarin): Safe after 12 weeks; A Pregnant Patient with Left-Sided Heart switch back to Heparin in the last month to Failure - the left ventricle can’t pump enough blood prevent coagulation disorders. (clotting forward, leading to a backup of blood in the lungs. issues) Causes: c