徐丽华
上海交通大学护理学院
2006 － 4 － 27

 Development standard of care, certification, advanced practice nurses
 Home Health care for postpartum women, discharge from Hops. 12-24 hours after delivery, high risk infants discharge home earlier than before
 Consumer involved in the childbearing care: Child birth class, sibling present, breast-feeding, birthing environment (LDR, LDRP), father’s involvement, parents leave option for family with newborn

Maternal Nursing concerns areas
 Prenatal care
 Low birth weight
 Mother and infant with HIV infection
 Adolescent pregnancy
 Drug and substance abuse during pregnancy
 Social/family stress and impacts to pregnant women and family
 Use and care for pregnant women

 Violence
 Sexual Transmitted Diseases: HIV/AIDS
86% of pediatric AIDS cases are transmitted through vertical transmission of
HIV
 Substance abuse
 Other diseases: Heart diseases, cancer, osteoporosis, eating disorders

Ovarian Cycle:
1. Follicular phase: stimulated with FSH to promote the development of follicles
Estrogen-follicle mature-negative feedback to hypothalamus and anterior pituitary gland – inhibiting FSH secretion
2. Ovulation: increase in body temperature
(progesterone secretion), fern pattern of the cervical mucus, spinnbarkeit “elasticity of the ovulatory”due to secretion of the estrogen

3.Luteal Phase: Corpus luteum and anterior pituitary gland will secret luteinizing hormones (the decrease in Estrogen and progesterone – positive feedback to
Hypothalamus and anterior pituitarystimulating the secretion of FSH
4. Premenstrual phase: Decline in estrogen and progesterone

Endometrial Cycle:
1.
Proliferative phase
2.
3.
Secretary phase
Menstrual phase

FSH stimulates which processes in the menstrual Cycle? a.
b.
Thinking of endometrium
Maturation of follicle c.
d.
Decrease in basal body temperature
Increase in progesterone production

4.
5.
6.
7.
1.
2.
3.
 Infertility affects 15-20% of the populations in the reproductive years
Terms to be understood:
Artificial insemination
Endometriosis
Laparoscopy
Primary Infertility
Secondary Infertility
Varicocele
Endometriosis





In vitro Fertilization/embryo Transfer
Gamete intrafallopian tube transfer (GIFT)
Zygote Intrafallopian Transfer (ZIFT)
Testing of infertility:
1.
2.
3.
4.
Ovulatory Analysis
Sperm Analysis
Testing of STDS
Tubal Patency test

In which phase of the menstrual cycle is thick, scant cervical mucus and an elevated BBT seen?
1.
2.
3.
4.
Estrogenic phase
Menstrual Phase
Ovulatory phase
Luteal Phase

 Clomiphene “Clomid”-risk of multiple ovulation
 hCG: to facilitate the ovulation , side effect ovarian over-stimulation
 hMG + Menotropin: Human Menopausal gonadotropin
 Danazol: suppresses ovulation and secretion of
FSH and Luteinizing hormone to inactive ectopic endometrial tissue. Side effect-Wt gain, hot flashes, decreased breast size, vaginitis

 Identify problems and strengths:
 Self-esteem disturbance related to diagnosis
 Personal Identity disturbance, related to unsuccessful infertility treatment
 Ineffective family coping, compromised live and decision making
 Nurse =supporter, advocate, counseling,

 Legal/ethical Decision making dilemmas
 Counseling regarding pregnancy termination
 Psychological impact of pregnancy termination
 Risk and complication associated
 Grief/guilt/ambivalence/uncertainty feeling after terminating of pregnancy

 Chamydia trachmatis infection
 Gonorrhea
 Human Papillomavirus
 Herpes Simplex Virus type 2 infection
 Cytomegalovirus infection
 Syphilis
 Vaginitis
 Human Immunodeficiency Virus Infection

Women should be taught to be aware of early warning signs of HIV infection which are: a.
b.
Dyspareunia
Severe dysmenorrhea c.
d.
Occasional Candida infection
Recurrent episodes of genital warts

The purpose of taking Tamoxifen after a mastectomy is to: a.
b.
c.
d.
Alleviate cancer pain
Act as hormonal replacement therapy
Block tissue uptake and utilization of estrogen
Destroy any stray cancer cells in remaining breast tissue

Family System Changes During The
Childbearing Cycle
 Structure
 Power
 Boundaries
 Affect or feelings
 Intergenerational patterns and roles
 Communication patterns
 Cultural background and riturals

 Bonding is affected by Maternal-Sensitive period.
 Attachment is developed through out the first year of life.
 Important for nursing practice: do not make inaccurate judgment, understand that childbearing is a major transition I the life of a family

Precrisis: Predictable and development events in the life cycle
1.
Discuss change with family structure, adding new member
2.
Assess risk factors, past coping and problem solving
3.
4.
Implement health teaching
Implement health promotion and maintenance strategies

Crisis: Coping strategies not sufficient to deal with changes in family structure and problem in development
1.
Clarify the problem
2.
3.
4.
5.
Assist the family in going an understanding of the situation
Acceptance of the family
Use appropriate interpersonal and institutional resources
Assess family to express feeling & ways of solving problem

Postcrisis: Crisis has been resolved, leading to a higher, the same, or lower of family function
1.
2.
Support the family in its new strategies of resolution
Emphasize growth potential in solutions
3.
Attempt to reverse or lessen effects of maladaptation through appropriate rehabilitative effort or therapy

1. Psychosocial Change in the mother:
Accepting the pregnancy
– Symbolic meaning of the pregnancy
– Self-image and body image during pregnancy

2. Role Assumption and maternal Adaptation
 Maternal Identity
 Maternal role attainment: Motivation for motherhood, preparation for motherhood, conflict resolution, maternal attachment behavior, relationship with mother
 Role conflict and attainment of the maternal role

 Inability to achieve the “good Mother”role
 Lack of knowledge and preparation for the maternal role
 Establishing a relationship with the fetus

Maternal Ambivalence in Pregnancy
 No questions asked about pregnancy, labor and delivery, infant care
 No interest in fetus
 Past negative experience with pregnancy or labor and delivery
 Denial of pregnancy and fetal movement
 Pregnancy and parenthood interfering with life style
 Continue activities that may hurt the fetus
(smoking or drinking)
 Reporting persistent and many physical complains.

 Check by Indirect Coombs test to detect antibodies in the serum that target red blood antigens to cause fetus hemolysis
 Antibody titer > 1:16 indicates possibility of severe hemolytic diseases
 Mother with Rh-negative: should receive Rhogam within 72 hours (any invasive procedure that may cause the mixing of the maternal blood with fetus)

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•
•
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3. Psychosocial Change in the father:
Development of the father role
Participation in the childbearing cycle
Father-infant interactions and the father role
“The Couvade Syndrome”-bodily symptoms experienced by a father during the course of his partner’s pregnancy.
4. Psychosocial Change in Sibling view


1.
2.
3.
4.
5.
Key terms:
Acquaintance
Ambivalence
Attachment
Avoidance
Bonding

Mrs. H. 33 wks shared that her husband was afraid of harming the unborn baby during intercourse.
Which is the best response of the nurse?
A.
“Gentle vaginal intercourse is safe throughout pregnancy”
B.
C.
D.
“each couple has a unique situation, bring your husband in for a talk with the doctor”
“The baby is well protected by your tissues, but if contractions occur, abstain and notify the doctor”
“vaginal Penetration is prohibited anyway during the last month of pregnancy because of the dangers of infection”
3

When teaching prospective fathers about pregnancy and birth, the nurse should plan to include which priority information?
A.
B.
The possible difficulties in each trimester
The cost of caring and raising a child
C.
D.
The normal range of feeling that may experienced in different stages of pregnancy
The importance of his role in the act of conception and in the determination of the sex of the fetus.
3

 First Trimester: 2-4 pounds (0.9-1.8 kg), 1 pound per week (0.45 kg) during 1 st & 2 nd trimester
 Total weight gain 13.18 kg or 29 pounds

 Obesity: recommend to gain wt 7-11.5 kg
 Underweight
 Teenage pregnancy: low wt gain during pregnancy, associated with LBW infant
19% of the baby wt < 2000 gram decrease 7.4% of LWB infant if wt gain improve to 11kg (25 lbs).
Frequent meal skipping and consumption of fast food (high salt, sugar, low vit and minerals)

 Gestational diabetes
 Urinary tract infections
 Inadequate weight gain
 Wound infection
 Thromboembolism
 PIH
 Fetal monitoring difficulty
 Prolonged labor
 Fetal Macrosomia
 Birth trauma

In comparison with a single fetus pregnancy, nutrition needs when there are twins much include: a.
Increased calorie intake of 300 per fetus each day b.
c.
d.
Low-salt foods to prevent edema
Additional fluid intake of 2-3 glasses per day
Iron and folic acid needs for 10% more per day

 Headache
 Altered vision: blurring, double vision, seeing spots
 Nausea/vomiting
 Epigastric pain/abdominal pain
 Muscular irritability/seizures
 Signs of infection:fever, burning in urination, flank pain, diarrhea,
 Vaginal bleeding
 Decrease or cessation of fetal movement

 “open” neural tube defects leak alphafetoprotein (AFP)
 Elevate AFP level in maternal serum and amniotic fluid may indicate the fetus has neural tube defects

 Performed around 15-18 weeks of gestation to identify genetic abnormality

1.
2.
3.
Risk:
Trauma to the fetus, placenta, umbilical cord, or maternal structures
Infection
Premature labor and spontaneous abortion

Warning signs after receiving amniocentesis:
1.
Body temperature elevation
2.
3.
Fluid leaking from the vaginal
Mild Cramping and abdominal aching
4.
Decreased fetal movement

 To detect genetic or chromosomal defects
 Can be done in early pregnancy 9-10 weeks gestation
 Risk: miscarriage 3.7-7.7%, 1.7% discrepancy of result between villus karyotype and fetus, rupture amniotic sac, chorioamnionitis, oligohydramnios, intrauterine growth retardation

 Check fetus well-being
 Check fetal movement in relation to fetal heart rate acceleration
 Reactive: HR acceleration with fetus movement
 Non reactive: no HR acceleration with fetus movement

 Autosomal Recessive Disorders: 25% of the
Risk of passing the disorder to each of their offspring. 1:4 chance of demonstrating the disorder, 50% change of being a carrier to the recessive trait, each child has 25% chances of not having the diseases and not being a carrier
-Cystic fibrosis, PKU, Sickle cell anemia,
-X-linked disorders: Hemophilia, color blindness,
G6PD

 Perform Karyotype examination
 Genetic Counseling-support for decision making
 Genetic screen for potential risk



Nausea/vomiting-morning sickness
Ptyalism “excess saliva in the mouth”
 Altered taste
 Bleeding gums
 Breast tenderness
 Urinary frequency
 Nasal stuffiness and Epistaxis
 Increased vaginal secretion
 Fatigue

 Promoting client safety: home, work, lifestyle, environment, danger/warning signs of pregnancy
 Removing barriers: Social Economic factors, lack of insurance, inability to pay, lack of free prenatal service, limit access to prenatal care for economically poor women, limited or expensive transportation, small children, cultural

Psychologic changes and concerns of a mother at 2 nd Trimester
 Aware of that the pregnancy can be recognized by others
 Acceptance of pregnancy
 Maternal role attainment: fetus movement fosters internalization and fantasy
 Fantasies: binding to infants
 Relationship with mother
 Body image: begins to view fetus as separate form own body, change the perception of body boundary as protective barrier to fetus

The nurse should assess for which developmental task of the pregnant women in her third trimester? a.
b.
Bonding to the fetus in preparation for birth
Accepting the fetus as a wanted responsibility c.
d.
Understanding the baby is an independent being
Preparing to separate from the fetus through the birth process

The nurse teaches the newly pregnant diabetic the importance of self glucose monitoring in the first trimester to prevent: a.
Hypoxia in the fetus b.
c.
d.
The onset of diabetes in fetus
Unusually large fetal development
Teratogenic effects of hyperglycemia

Magnesium Sulfate may be prescribed as a tocolytic drug because one of the expected actions is: a.
Promoting diuresis b.
c.
d.
Lowering blood pressure
Inducing sedation and rest
Promoting smooth muscle relaxation

 Analgesia: demerol (meperidine)
 Sedative: Seconal and Nembutal
 Narcotic analgesics: Fentanyl, Stabol
 Anesthesia: Marcaine (Bupavacaine)
Alfenta (Alfentani)

 Give to women in 2-4 cm Cx dilation
 Giving anesthesiologist into epidual space at L-2,
L-3, L-4 or L-5
 Provide pain relief in lower part of body
 Labor stimulation by Oxytocin may need
 Prevent Hypotensive effect (500-1000 ml Lactated
Ringer’s)
 Monitoring uterus contraction and fetus condition

 Respiratory depression in newborn (Narcan)
 Pruitus (itching)
 Nausea and vomiting
 Urinary retention
 Hypotensive
 Affect labor process, unable to push during second stage of labor (assessment important)

A Client has received an effective dose of epidural anesthesia. The IV rate is 250 ml/hour and position is semi-Fowler’s. Her blood pressure has dropped significantly. The first nursing intervention is to: a.
Slow the rate of IV infusion to avoid overload b.
c.
d.
Retake the BP, initial hypotension is expected
Begin oxygen by face mask, lower head, elevate legs.
Call back anesthesiologist to deal with the condition

 Induction: starting labor artificially by oxytocin
 Augmentation: stimulation of labor once it has begun naturally.
 Amniotomy: color of the amniotic fluid
 Assess risk: frequency of contraction, maternal tolerance, pain, fetus well-being, discomfort, progress of labor, complication

The nurse teaching the Lamaze technique evaluates her success when the couple do the following: a.
Break the fear/tension/pain cycle b.
c.
d.
Bond successfully with the newborn
Use positive feedback with each other during labor
Maintain control during labor by their techniques of breathing and relaxation

In developing childbirth classes the nurse plans to include techniques that normally minimize pain perception, which of these are inappropriate? a.
b.
Using muscle relaxation methods
Invalidating the perception of pain c.
d.
Refocusing attention on another subject
Implementing anxiety reduction techniques

In developing childbirth classes the nurse plans t include techniques that normally minimize pain perception, which of these are inappropriate?
a.
b.
Using muscle relaxation methods
Invalidating the pain perception c.
d.
Refocusing attention on another subject
Implementing anxiety reduction techniques

 Repeat CS in USA 80%
 Fear of weakening the uterine scare
 Twice Maternal Risk in C/S than in Vaginal birth
 Qualification: primary cesarean not due to pelvic factors. “Classic uterine incision???”
 Support of staff and women’s desire to have vaginal birth are optimal factor for trying VBAC

When membranes rupture spontaneously during labor, the nurse at the bedside must immediately: a.
Monitor fetal heart rate b.
c.
d.
Change the bed ped and give peri care
Increase the flow rate of intravenous fluid
Report the color and consistency of the fluid

During labor, while lying supine in bed, Millie
M. States she feels dizzy and weak, vital signs show an elevated pulse and lowered
BP, the nurse should first: a.
Notify the physician b.
c.
d.
Check for vaginal bleeding
Apply oxygen by mask at 10 L/min
Rotate her to the left side-lying position

Five hours prior to arriving at the DR, your client’s amniotic membranes ruptured, which is a priority in the nursing planning?
a.
b.
Monitoring urinary output hourly
Providing frequent perineal care c.
d.
Increasing fluid intake intravenously
Assessing temperature at least every 2 hours

During transitional labor, when the fetal heart rate tracing shows a drop of 50 beats for 20 seconds and the rate returns to baseline, which is the first nursing action? a.
b.
Call for physician at once
Turn client toward the left lateral position c.
d.
Position client to relieve pressure on the cord
Do nothing, continue to observe since there is a rapid return to baseline

 Colostrum: contain Immunoglobulins G and
A (Ig G, Ig A) to protect newborn’s gastrointestinal System
 Secretion stage: prolactin hormone
 Let-down reflex: Neurohormonal Reflex primary responds to infant’s sucking, posterior pituitary gland secretes oxytocin.

Which would indicate to the nurse that the newborn may be hypoglycemic?
a.
b.
Hyperthemia with flushed skin
Residual tremors after movement c.
d.
Vigorous sucking on nipple or on fist
Frequent loose stools