NCM 209
Care of Mother, Child, and Population Group at Risk or
with Problems
• ampulla (fallopian tube) – egg and sperm
fertilize
• ovulation – 14 days after mestruation
PRENATAL CARE – prevent occurrence of complication
- THE PURPOSE OF PRENATAL CARE IS TO ENSURE
AN UNCOMPLICATED PREGNANCY AND THE
DELIVERY OF A LIVE AND HEALTHY INFANT.
BALANCE OF FORCES IN PREGNANCY
• FETAL SURVIVAL
• MATERNAL SURVIVAL
5 Branches of Maternal Health
• Nutrition – fat and protein demand (2nd half)
• Prenatal Care – DOH
standard prenatal care
(2004)
• Safe Delivery
• Breastfeeding
• Family Planning
Prenatal Care
• Regular prenatal care increases the chances of a
healthy mother and child after birth.
• Early detection of congenital & birth defects
• Prenatal immunizations can prevent mother-tochild-transmission and infection. (dec. the risk
of infections and diseases)
DOH STANDARDS OF PRENATAL CARE
1. WEIGHT – pattern of weight is more important than
the amount of weight gained
2. HEIGHT
BMI:
<18.5 = underweight (intrauterine growth retardation)
18.5-24.9 (18.5-20.8) = normal
25-29.9 (29) = overweight (preeclampsia; edema)
30-34.9 = obesity I
35-39 = obesity II
40 above = extreme obesity
2nd to 3rd trimester
- inc. 340 (330) kcal
- inc. Vit. C = help dec. risk of premature rupture of
membrane (PROM)
= help inc. cervical collagen
helps ripen
and promotes effacement and dilatation of
cervix during delivery
- folic acid (doubled) = reduce risk of neural tube
defects
3. BLOOD PRESSURE
- 10 mmHg systolic and 15 mmHg diastolic (normal)
- diastolic = 100 BP on close watch (borderline) – BP
might continue to rise
4. FHT
- 120-160 bpm; regular and strong (normal)
- inc. or dec. = gasping for oxygen
5. FUNDIC HEIGHT
- measurement of symphysis pubis
- uterine size correlates with the fetal growth
• 5th month = 20 cm (umbilicus)
• 6th month = 21-24 cm
• 7th month = 25-28 cm
• 8th month = 29-30 cm
• 9th month = 30-34 cm
6. LEOPOLD’S MANEUVER – fetal presentation, position,
lie, attitude
* let patient void to prevent discomfort
fir
A. Fundal Grip – presenting part; presentation,
position (right hand = push, left hand = palpate)
B. Umbilical Grip – extremeties, fetal back, and
FHT (usually in the LLQ); position
C. Pawlick’s Grip – engagement
D. Pelvic Grip – attitude; degree of flexion (head)
7. TT IMMUNIZATION
TETANUS TOXOID
WHEN TO GIVE
TT 1
ANYTIME DURING
PREGNANCY
TT 2
4 WEEKS AFTER TT 1
TT 3
6 MONTHS AFTER TT 2
TT 4
1 YEAR AFTER TT 3
TT 5 – booster dose
1 YEAR AFTER TT 4
8. DIET
• Calories
• Proteins – tissue growth and repair; growth of
maternal tissues
• Water – all body tissues
• Calcium – bone and tooth miniralization and
calcification (mother and fetus)
• Vitamin D – for calcium to be absorbed by the
body
• Iron – blood loss
9. DANGER SIGNS OF PREGNANCY
a. vaginal bleeding (no matter how small – seek
medical attention)
b. inc. temp which cannot be relieved by
antipyretics
c. difficulty in urinating = edema, headaches, inc.
BP
d. swelling of breasts
e. blurring of vision
f. tingling sound of ears – pregnancy induced
hypertension
g. postpartum blues
postpartum depression
10. BREASTFEEDING
• RA 7600 – Rooming In and Breastfeeding Act of
1992
• EO 51 of 1986 – Milk Code (signed by former
pres. Noynoy Aquino)
• RA 10028 – Expanded Breastfeeding Promotion
Act of 2009 amendinf RA 7600
11. FAMILY PLANNING
Methods:
• Natural
o Abstinence
o Fertility Awareness Method (FAM) – like
calendar method
o Lactation Amenorrhea Method (LAM)
o Basal Body Temperature (BBT) – check
temp every morning; fertile = inc. temp
o Billings’ Method – base on vaginal mucosa;
secretions
o Symptothermal Method – combination of
BBT and Billings’
• Artificially
o Intrauterine Device (IUD)
o Oral Contraceptive Pills (PO)
o Depo Provera Injectables – white and
cloudy (IM)
o Implant – suppress ovulation (lasts for 3
years)
o Condom
o Cervical Cap – to close the cervix
o Spermicidal Gel – gel that kills sperm
• Surgical Contraceptive
o Tubal Ligation
o Vasectomy
12. POSTPARTUM CARE
- includes breastfeeding, diet, hygiene, meds, getting
ready to go home health teachings
- plain water for breast washing before feeding
- perineum is susceptible to infection, bruises,
lacerations
- lochia can be a cause of infection
- perineal care: front to back
- elimination process: empty bladder every 4-6 hrs
after delivery
- decrease in aldosterone = decrease in sodium
retention
• Intake and Output: monitored due to risk for urinary
infection urinary stasis catheterization
• constipation is common due to slow peristalsis
• prevention of back strain
• infant needs
o sleep 16-20 hrs/day
o eat 2- 4 hrs
o wake when sleeping to eat
• When am I going to feed by baby when awake?
o infant signals : hand raising and opening, when
baby turn to you when you rub his/her cheek
with your finger/cloth
o bathe baby 6 hrs after delivery
o breastmilk has different colors depending on
mother’s intake
o breastmilk in fridge:
▪ single door: 2 weeks
▪ double door chiller freezer: 3 months - 6
months
▪ deep freezer: 1 year
*if milk bottle has been opened and consumed but has
left overs, never return in the bottle and in the fridge
*if mother complains of sore nipples, assess, encourage
use of pump, DO NOT stop breastfeeding and DO NOT
use formula milk
High Risk Mom
According to DOH:
- 1st pregnancy = hospital delivery
to prevent
maternal death
- lying ins do not accept pregnant mothers for delivery
without prenatal care to prevent maternal death
What is High Risk Pregnancy?
poor maternal or fetal outcome due to :
 medical – no prenatal checkups
 reproductive – having early or late
pregnancy (highly recommended age:
25 years old)
 Psychosocial
 Obstetrical – delay on decision to look
for a place to deliver baby
 SCREENING
Diagnostic and Laboratory Examinations
Screening – identifies patients who are at risk
Diagnostic Test - confirmation of a particular
disease
COMPLETE BLOOD COUNT
➢ Hemoglobin
▪ helps determine if pt. has anemia,
polycytemia (abnormally high
erythrocytes count; high risk for
jaundice – liver damage), assess pt. to
treatment (see if there are
imrovements)
▪ anemia = less oxygenation, dec. RBC
content (due to dec. hemoglobin and
erythrocytes = fatigue, fainting)
o physiologic anemia – alleiviated
by repositioning; nursing
interventions
o pathologic anemia – bone
marrow supression
▪ inc. hemoglobin = dehydration
o 14-18 g/dL – males
o 12-16 g/dL – females (lesser
than males because of
menstruation)
➢ Hematocrit
▪ amount of space/volume of RBC takeup
in the bood
▪ dec. hematocrit = anemia, hemodilation
▪ inc. hematocrit = hemoconcentration,
polycytemia caused by blood loss
➢ Leukocyte (WBC)
▪ inc. leukocytes = indicates infection
➢ Thrombocytes (platelet)
▪ smallest type of blood cells
▪ for blood clotting
▪ inc. thrombocyte = blood clot forming in
the blood vessels
o alteration to oxygenation of the
brain = stroke
o hardening of blood vessels
(part. arteries) = atherosclerosis
➢ Blood Typing
▪ may be part of NCP or NI pt. with
CBC related complications
➢ Rhesus Factor
▪ isoimmunization (+/-) or sensitization
URINALYSIS
- determine if pt. is drinking enough water (6-8
glasses a day)
- signify nephrological order
- blood content (yellow almost red)
➢ Pus cells – identify if mother is having UTI
(predispose fetus to intrauterine growth
retardation, nephronia; mother to
nephrolithiasis, hypertension)
➢ Bacteria – “
➢ Protein/albumin – (+) = pregnancy induced
hypertension (PIH)
➢ Sugar – GDM/ history of DM
➢ Squamous epithelial cells – inflammation to
urinary tract system
PAP SMEAR (Papanicolaou Smear)
- Procedure to check cervical anomalies
ULTRASONOGRAPHY
➢ Transabdominal – noninvasive, painless; *allow
pt. to empty bladder
➢ TRANSVAGINAL ULTRASOUND – inserted in
vagina; to clearly show where cells are forming
*full bladder/partially full or empty bladder
- to justify AOG of patient
- observation of FHT at 11 weeks
- measurement of biparietal
- determine birth weight (macrosomia)
- location of placenta
- identify placental grading (detect fetal death) –
FDIU (remote areas)
BLOOD GLUCOSE TEST
- detect sugar level in body
➢ FBS (Fasting Blood Sugar)
▪ no intake/ NPO for 8 hours
▪ test for iron deficiency (fasting 12
hours)
▪ N: 100 mg/dL
▪ DM: 125 mg/dL
▪ Borderline: bet. 100 and 125 mg/dL
➢ HGT (Hemo Glucose Test)/CBG (Capillary Blood
Glucose)
▪ consentration of blood glucose in the
blood
▪ N: 72-99
▪ HGT = ward
▪ 5 hours before meal
▪ 2 hour before procedure
➢ OGTT (Oral Glucose Tolerance Test)
▪ tested on blood samples
▪ normal diet for 3 days and no diuretics
before test
▪ 10 hours fasting
▪ patient should be at rest
▪ done early in the morning
➢ OGCT (Oral Glucose Challenge Test)
▪ tested on urine and blood samples
▪ checks how body takes glucose
▪ test for GDM
▪ prior to test, 50 g intake of sugar; after
1 hr, take blood and urine samples
➢ 2 HRS. POST PRANDIAL
▪ Test blood glucose
▪ Done after meal
▪ 75 g of sugar/carbohydrates
AMNIOCENTESIS
- examination to take amniotic fluid (invasive)
- guided by ultrasound
- detect genetic abnormalities and fetal lung
maturity
- risk: fetal infection, rupture of membrane, preterm
labor, fetal injury
▪ Chorionic Villi Sampling
o to determine fetal karyotype
o performed 10 to 12 weeks AOG
o uses bigger syringe (50 cc syringe)
o 1 out of 200 are at risk
o complications: fetal loss, RBOW,
possible fetal limb reduction
Maternal Alpha-Feto Protein
- to detect neural tube defects
Fetal neural tube defect:
➢ anencephaly – birth defect, baby is born
without parts of brain and skull
➢ gastroschisis defect in abdominal wall; baby’s
intestines are found outside baby’s wall
➢ spina bifida – failure of closure of caudal end;
can’t walk most of the time (undergo PT)
➢ 2 major serum proteins (synthesized
predominantly on the liver and yolk sac)
▪ Albumin
▪ Alpha-Feto protein
DOPPLER VELOCIMETRY
- waves that measure the velocity of RBC movement
(non-invasive)
- decreased = associated with poor neonatal
outcome; deformities
PERCUTANEOUS UMBILICAL BLOOD SAMPLING
- complications: cord lacerations, preterm labor,
premature rupture of membrane,
thromboembolism
BIOPHYSICAL SCORING
30 minutes observation by USD
5 markers:
➢ non stress test
- hypoxemia (low level of oxygen in the
blood)
- hypoxia (inadequate oxygen delivery to
body tissues)
- FHR reacts with movement
hypoxia
leads to acidosis
- 32 to
- 120-160 (at rest)
- Ex. 162 (moving)
➢ fetal breathing
- inc. 2 within 1 episode
- 30 sec. (per episode)
- more than 30 (abnormal)
➢ amniotic fluid
- 20 cm (hydramnios)
- 5 cm below (oligohydramnios)
- more than 30 (polyhydramnios)
- N: 50-20; start to decrease at 39 weeks
➢ fetal body movement
- done after 27 weeks AOG
- expect for 3 or more movements of body
and limbs
➢ fetal tone
- N: 120-160
-
Flexion seen in biophysical scoring in
ultrasound
BPS RESULT INTERPRETATION
8 – 10 - Normal fetus
6 - chronic asphyxia
- repeat the procedure after 24 hours
4 - abnormal result
2 - ill fetus, terminate pregnancy
NON STRESS TEST (NST)
2 - 2 or more FHT acceleration
per movement
1 - <2 accelerations
per movement
0 - no acceleration
FETAL BREATHING
2 - 1 episode/30 minutes lasting 30 seconds
0 - no episode
- more than 30 minutes
- not lasting 30 seconds
AMNIOTIC FLUID INDEX
2 - fluid filled pocket of 1 cm or more
0 - no amniotic fluid or less than 1 cm in every
pocket
FETAL BODY MOVEMENT
2 - 3 or more discrete movement of limbs and
body in 30 minutes
1 - less than 3 movements
0 - no movements
FETAL TONE
2 - 1 or more episodes of active extension with
return to flexion of limbs and trunk
1 - slow extension with return to flexion
0 - no movements
HEPATITIS B DETERMINATION
- Quantitative = serum titer check; degree of
immaturity to disease or virus
- Qualitative
1 Hepatitis B Antigen (HBSAg)
2 reactive - positive
3 non-reactive – negative
4 Hepatitis B Antibiodies (HBSAb)
➢ qualitative
➢ quantitative
CONTRACTION STRESS TEST (CST)
➢ done after 32 weeks AOG
➢ EFM – record response of FHR to stress
induced by uterine contraction; *check
FHR after contraction (fetal distress)
➢ Negative - normal; no fetal heart
deceleration
➢ Positive - abnormal; with deceleration]
➢ stimulate nipple = help contraction
(monitor)
➢ IV (oxytocin) = continuously monitor
FETOSCOPY
- Direct visualization of the fetus through a scope
- Obtain sample tissues or blood
- May perform intrauterine fetal surgery
FETAL MOVEMENT COUNTING
- Done after 27 weeks AOG
- Twice daily for 20-30 minutes
- Normal – 5-6movements in 20-30 minutes
- Abnormal – less done 3 movements in 1 hour
MEDICAL COMPLICATIONS DURING PREGNANCY
• CARDIOVASCULAR DISORDERS (most common)
PREGNANCY
➢ Increase blood volume 40 – 50% - double
record due to growing fetus
➢ Increase cardiac output
➢ Decrease B during first trimester
➢ Increase size of ventricular chamber
❖ LEFT TO RIGHT SHUNTING
- septum completely absent; foramen ovale...
❖ ATRIAL – SEPTAL DEFECT
➢ asymptomatic
➢ increase pulmonary blood flow
➢ pulmonary hypertension
❖ VENTRICULAR SEPTAL DEFECT
➢ left ventricular hypertrophy
➢ pulmonary hypertension
➢ biventricular hypertrophy
➢ no separation; septum not closed, inc. blood
flow = pulmonary hypertension
❖ PATENT DUCTUS ARTERIOSUS
➢ rare
➢ early surgical repair
➢ similar with VSD
➢ no valve
➢ instead of aorta, goes to pulmonary artery
➢ hole bet. aorta anf pulmonary artery
❖ RHEUMATIC HEART DISEASE
➢ Group A Beta Hemolytic Streptococcus
➢ Inflammatory process
➢ Autoimmune disease
➢ Scarring of the valves – stenosis of the valve
➢ Common in tonsilitis
➢ inc. blood volume = inc. cardiac output
✓ SIGNS AND SYMTOMS OF CARDIAC DISEASES
• Shortness of breath – exertions
• Palpitations
• Orthopnea - breathlessness
• Expectoration of blood – vomit blood
• Cyanosis – bluish discoloration
• Murmur – extra heart sounds
• Heart enlargement – inflammation
o
✓ FUNCTIONAL CLASSIFICATIONS OF CARDIAC
DISEASES
• CLASS 1 - asymptomatic = no limitations
• CLASS II - symptomatic but with normal
activities
• CLASS III - symptomatic and with less
than normal activities
enlargement of jugular vein – right
sided
• CLASS IV - symptomatic and at rest
- inability to carry any physical
activity
- contraindicated to have any
physical activity
JUDGMENT OF SAFETY OF PREGNANCY
Conception should be prevented if:
1. Severe heart disease
2. Functional classification: class III-IV
3. History of heart failure
4. Pulmonary hypertension
5. Right to left shunting
6. Severe arrhythmia
7. rheumatic fever
8. Combined valve disease
9. Acute myocarditis
MANAGEMENT OF CARDIAC DISEASES
o termination of pregnancy by CS
• Weight reduction
• Rest
• prevent infection
• Digoxin – calcium channel blocker (help
with contraction of heart)
• Diuretics – water pills that help get rid
of sodium and water
Two types:
▪ Potassium-sparing diuretics
- needed for heart contraction
= inc. urine output, sparing
potassium
▪ Plain diuretics
NURSING CARE OF CARDIAC DISEASES
➢ Vital signs
➢ Provide rest
➢ Emotional support
➢ I & O monitoring
➢ Proper nutrition – dec. sodium intake, avoid
fats/oily foods
➢ Carry out medical orders
•
GESTATIONALDIABETES MELLITUS
- will only occur during pregnancy
- metabolic diorder = characterized by
hyperglycemia
- result to insulin depletion
- impaired of carbohydrate metabolism
Two classifications:
▪ TYPE I (diagnosed at an early age)
o formerly called “insulin dependent”
o common to younger individuals
acute: polyuria, polydipsia, weight
loss
▪ TYPE II (diagnosed to older patient;
current obesity)
o most common
o insulin resistance – inadequate
insulin production
o free from symptoms
o may lead to ketoacidosis
RISK FACTORS CAUSING GDM
➢ Obesity
➢ Family history
➢ Personal history
➢ Sedentary lifestyle
➢ Improper diet
PATHOPHYSIOLOGY
GDM = chronic disorder
- Body requires energy
Human Placental Lactogen + diabetogenics
(cortisol, glucagon, adrenaline,
growth hormone)
Decrease Insulin sensitivity
Hyperglycemia
Estrogen &
Progesterone
crosses placenta
Hyperinsulinemia
(fetus large in size)
Fetal Hyperglycemia
Build up of fat
(macrosomia)
Increased
insulin
Fetal Hyperinsulinemia
Growth
hormone
Increase ATP in cells
MACROSOMIA
1. anabolic phase
2. catabolic phase
(usually happens on 2nd
phase or second half)
Respiratory Distress
Syndrome
FETAL/NEONATAL COMPLICATIONS OF GDM
➢ Fetal hyperglycemia – high blood glucose
➢ Fetal Hyperinsulinemia – high insulin production
➢ Macrosomia – result of high maternal level of
blood glucose from fetus derives glucose
➢ Prematurity – born before 37 weeks of
gestation
➢ Respiratory Distress – result of high levels of
insulin, fetal enzymes needed for surfactant in
lungs (by fetus), dec. production of lung
surfactant
➢ Neonatal Hypoglycemia – low blood glucose
MATERNAL COMPLICATIONS OF GDM
➢ Preeclampsia
➢ Polyhydramnios – high amniotic fluid index;
result in fetal urination = fetal hyperglycemia
➢ Infection - glaucoma
➢ Dystocia – inappropriate pubic bone : shoulder
➢ Postpartum Bleeding – laceration, incision,
episiorrhaphy, ectopic pregnancy, hemorrhage,
uterine atony
➢ Birth canal trauma – large baby, not
proportionate pelvic inlet
➢ Caesarean delivery – CPD, fetal distress,
macrosomic baby
Fasting & 2 hours postprandial venous plasma sugar
during pregnancy.
FASTING
RESULT
<100 mg/dl
2HRS POST
PRANDIAL
< 145mg/ dl.
>125 mg/ dl
>200 mg/ dl.
Diabetic
Not diabetic
ORAL GLUCOSE CHALLENGE TEST
➢ fasting post-midnight
➢ blood and urine specimen are obtained
➢ 50 grams glucose intake
➢ after 1 hour, blood and urine specimen is
obtained
➢ A value above 130 – 140 gms/l one hour after
is used as threshold for performing a 3-hour
OGTT.
Prerequisites of OGTT:
➢ Normal diet for 3 days before the test.
➢ No diuretics 10 days before.
➢ At least 10 hours fast.
➢ Test is done in the morning at rest.
CRITERIA FOR OGTT
The maximum blood glucose values during pregnancy:
• fasting
90 mg/dl
• one hour 165 mg/dl
• 2 hours
145 mg/dl
• 3 hours
125 mg/dl
MANAGEMENT OF GDM
➢ Insulin – normalize glucose level
➢ Diet – 3 meals, 3 snacks
➢ Exercise
Substance Abuse During Pregnancy
TERATOGEN
✓ Any agents that interferes with normal
embryonic development
ALCOHOL – patent teratogen (ethyl alcohol)
✓ CNS Depressant
✓ Reduce Anxiety
✓ Sedation
✓ Respiratory Depressant
ALCOHOL EFFECTS ON FETUS
➢ Fetal Alcohol Syndrome (FAS)
➢ Intrauterine Growth Restriction
➢ Preterm Delivery
➢ Missing limbs
Opioids (party drugs) – permanent damage to fetus
Maternal Effects:
▪ Spontaneous abortion
▪ Hepatitis
Neonatal Effects:
▪ Neonatal Withdrawal Syndrome –
hyperirritability (characteristic)
▪ Respiratoty Distress
▪ Autonomic Disturbances
▪ Gastrointestinal dysfunction
CNS Depressants:
➢ Morphine
➢ Heroin
➢ Methadone
➢ Analgesics
STIMULANTS – present in soda and coffee
➢ Cocaine
➢ Amphetamine
➢ Ecstasy
➢ Caffeine
EFFECTS OF STIMULANTS
➢ Increase Concentration
➢ Alertness
➢ Paranoia
➢ Hypertension
➢ Psychosis
STIMULANTS’ EFFECTS ON FETUS
➢ Preterm labor
➢ Spontaneous abortion
➢ Placental abruption
➢ Fetal hypertension
PREGNANCY SMOKING
Nicotine
- Overall reduction of fetal growth
- Vasoconstriction = dec. blood flow and supply of
nutrients
- Double risk of growth retardation
➢ Higher rates of spontaneous abortion, placenta
previa,
➢ Preterm labor
➢ Low birth weight infant
➢ Fetal hypertension
MARIJUANA
➢ Relaxant
➢ Hallucination
➢ Short term Memory loss
➢ Low birth weight Infant
Tetrahydroconnabinol
- active component of marijuana that crosses
placenta
- upto 30 days
Lifetime Effects of Substance Abuse
➢ Physical deformities
➢ Mental Retardation
➢ Developmental Problem
(END OF FIRST PRESENTATION)