lOMoARcPSD|28738202 Prenatal Care - lesson 1 Nursing (San Pedro College) Studocu is not sponsored or endorsed by any college or university Downloaded by Modern Day Samuel (moderndaysamuel@gmail.com) lOMoARcPSD|28738202 MATERNAL AND CHILD CARE NURSING OUTLINE I. II. III. IV. Course Description Prenatal Care Diagnostic and Laboratory Examinations Medical Complications During Pregnancy COURSE DESCRIPTION This course deals with the concept of disturbances and pre-existing health problems of pregnant women and the pathologic changes during intrapartum and postpartum periods. 5 BRANCHES OF MATERNAL HEALTH COURSE OBJECTIVES Nutrition The development of the baby depends on what the mother eats Prenatal Care For the safety of the delivery of the baby For the management and treatment of detected birth defects and other untowards complication Safe Delivery Breastfeeding Optional; depends on the mother’s perspective and level of understanding Family Planning Average gap of first pregnancy to succeeding pregnancy: 2-3 years At the end of the course, given actual or simulated situations/conidtions involving indiviudal client (mother, newborn baby, children) and family at risk/with problem, the student will be able to: 1. 2. 3. 4. 5. 6. Utilize the nursing process in the holistic care of client for the promotion and maintenance of health in community and hospital settings Assess with client his/her health condition and risk factors affecting health Identify actual/risk nursing diagnosis Plan with client appropriate interventions for identified problems Implement with client appropriate interventions for identified problems Evaluate with client the progress of their condition and outcomes of care Fig. 2 Breastfeeding Mnemonics PRENATAL CARE PRENATAL CARE The purpose of prenatal care is to ensure an uncomplicated pregnancy and the delivery of a live and healthy infant Problem arises even before conception if the mother has any pre-exisitng health conditions 1. 2. BALANCES OF FORCES IN PREGNANCY “Pag buntis ang babae, ang isang paa niya ay nasa hukay.” Giving birth is a matter of life and death. 3. Regular prenatal care increases the chances of a healthy mother and child after birth Prenatal check up should be completed Early detection of congenital and birth defects Through ultrasound as early as 8 weeks, then 20 weeks, then 38-36 weeks (to check if umiikot si baby, if breech position, if there’s any problem with fetal development, etc) Prenatal immunization can prevent mother-to-child transmission Anti-tetanus and vitamin A Tetanus Toxoid – 5 doses for lifetime immunity; will reach the baby since it circulates in the blood Fig. 1 Balances of Forces in Pregnancy 1 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D Downloaded by Modern Day Samuel (moderndaysamuel@gmail.com) lOMoARcPSD|28738202 DOH STANDARDS FOR PRENATAL CARE 1. Weight There should be a 5 pounds increase in the mother’s weight every week To ensure if weight gain is equal to the expected weight gain of a pregnant woman (weight gain of fetus, placenta, amniotic fluid) 2. Height 3. Blood Pressure Methyldopa is always the drug of choice 4. FHT Evaluate if the baby if baby is still alive and its movement Audible in 5 months/20 weeks Fundic Height Symphysis pubis to the fundus 5th month 6th month 7th month 8th month 9th month 20 cm 21-24 cm 25-28 cm 29-30 cm 30-34 cm When to Give Anytime during pregnancy 4 weeks after TT1 6 months after TT2 1 year after TT3 1 year after TT4 8. Diet If possible: adquate calorie, low carbs, more protein (muscle and bone development of baby) 9. Danger Signs of Pregnancy Assess: elevated blood sugar, unusual bleeding, premature uterine contraction, hypertension, PROM, dizziness, headache Unang Yakap 11. Family Planning 12. Postpartum Care Sickle cell anemia RBC is cresent-shaped There aren’t enough healthy RBC to carry oxygen throughtout the body Leukemia Low WBC Hemolytic anemia Ruptured RBC Iron, Folate, or Vitamin b12 Deficiency Influence the production and formation of RBC = Anemia if kulang Bone marrow disease Unable to produce healthy blood Chronic inflammatory disease An organ swells when there is inflammation which causes the capillaries to dilate. The capillaries will eventually rupture, causing bleeding and a low hematocrit.Internal bleeding Low platelet Kidney failure Erythropoietin (released by kidney) stimulates bone marrow to produce blood Kidney failure = no stimulation to produce healthy blood since walay erythropoietin Lymphoma Cancer on the lymphatic vessel (fluid and blood becomes trapped) What Does a High Hematocrit Mean? 10. Breastfeeding Hemoglobin – 120-160; 12-16 (female); 12-18 (male) Hematocrit – 36% - 48% Leukocyte – 4-11 Thrombocytes – 350,000 – 450,000/350-450 Blood Typing – a, b, ab, o Rhesus Factor – Rh (+) or (-) Erythrocytes – RBC: 4.5 – 6 What Does Low Hematocrit Mean? Leopold’s Maneuver Tetanus Toxoid TT1 TT2 TT3 TT4 TT5 For management and appropriate nursing care if patient has an abnormal result COMPLETE BLOOD COUNT are non-invasive method of assessing fetal presentation, position, and attitude. This technique can also be used to locate the fetal back before applying the fetal monitor 1. Fundal grip – fetal presentation 2. Umbilical grip – fetal position (back and extremities) 3. Pawlick’s grip – engagement (relationship to ischial spine) 4. Pelvic grip – fetal attitude (degree of fetal position) Ex. good attitude; flexion (neck is flexed) vertex presentation – neck is flexed, chin is touching the chest cephalobregmatic position – maganda ang vertex; perfect for NSVD 7. TT Immunization Poor maternal or fetal outcome due to: Medical Reproductive Psychosocial Obstetrical DIAGNOSTIC AND LABORATORY EXAMINATIONS 5. 6. HIGH RISK PREGNANCY Polycythemia Vera Poly – madami; cythemia - cell and blood = maraming cell sa blood Excessive increase of RBC, WBC, and platelet Kidney tumor Edema formation = more fluids and plasma Congenital heart disease Left side, right side shunting 2 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D Downloaded by Modern Day Samuel (moderndaysamuel@gmail.com) lOMoARcPSD|28738202 Dehydration More water = More hematrocrit = Excessive vomiting Excessive Diarrhea may lead to dehydration that makes our haematocrit high due to the loss of plasma Lung disease pneumonia, lung disease that causes increase in hematocrit Transvaginal ultrasound A probe is inserted inside the vagina URINALYSIS Pus cells Bacteria – Protein/albumin – PIH (if +) +1, +2, +3, +4 (highest, boiled egg) Sugar – GDM (-) glucose = no GDM (+) glucose = GDM Squamous epithelial cells - normal Fig. 5 Transvaginal ultrasound BLOOD GLUCOSE TEST PAP SMEAR Check cervical secretion Get sample for cervical biospy Get smaple for STI Get sample to check for RBOW or LBOW FBS 100-120 mg/dl HGT/CBG 80-120 mg/dl OGTT Oral Glucose Tolerance Test OGCT Oral Glucose Challenge Test 2 hrs. Post Prandial Additional Notes: OGTT Fig. 3 Pap smear ULTRASONOGRPAHY Done to check baby’s status inside, bag of water, fetal features, heart rate, placenta Transabdominal ultrasound OGCT Needs flavored juice 75g sugar Blood is extracted prior the test (1). Patient drinks the juice after obtaining the first sample. Blood is extracted again after 1 hour (2). This is done 2 more times with 1 hour interval each (3 then 4). Blood is extracted 4 times. First extraction: baseline Result: 2/3 elevated result = GDM OGTT and OGCT difference: gram of juice Needs flavored juice 50g sugar Blood is extracted prior the test (1). Patient drinks the juice after obtaining the first sample. Blood is extracted again after 2 hours (2). Blood is only extracted twice Over the fundus or abdomen Fig. 4 Transabdominal ultrasound 3 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D Downloaded by Modern Day Samuel (moderndaysamuel@gmail.com) lOMoARcPSD|28738202 AMNIOCENTESIS Aspiration of bag of water To detect congenital anomalies, trisomy problem, fetal defects Fig. 8 Anencephaly Fig. 9 Gastroschisis Fig. 6 Amniocentesis Fig. 10 Spina bifida CHORIONIC VILLI SAMPLING Check for possible problem/defect DOPPLER VELOCIMETRY uses ultrasound to check blood flow in the umbilical cord or between the uterus and the placenta To see the contractions if the waves are strong while the baby is inside the mother’s womb. Fig. 7 Chorionic Villi Sampling MATERNAL ALPHA-FETO PROTEIN To checks the level of AFP in a pregnant woman's blood AFP – substance made in liver of fetus Detect neural tube defects Spina bifida A condition that affects the spine and is usually apparent at birth. It is a type of neural tube defect (NTD). Spina bifida can happen anywhere along the spine if the neural tube does not close all the way. Anencephaly The absence of skull Gastroschisis Intestines are found outside the body They go straight to NICU and is scheduled for surgery for their stomach to be close in order for them to survive. Fig. 11 Doppler Velocimetry PERCUTANEOUS UMBILICAL BLOOD SAMPLING Cordocentesis, also known as percutaneous umbilical blood sampling, is a diagnostic prenatal test. During cordocentesis, an ultrasound transducer is used to show the position of the fetus and umbilical cord on a monitor. Then a fetal blood sample is withdrawn from the umbilical cord to test for fetal disorders 4 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D Downloaded by Modern Day Samuel (moderndaysamuel@gmail.com) lOMoARcPSD|28738202 Hepatitis B Antigen (HBSAg) Reactive – positive Patient should be isolated Nurses should double glove Non-reactive – negative Patient can stay in the labor room Hepatitis B Antibodies (HBSAb) Test that looks for antibodies that your immune system makes in response to the surface protein of the hepatitis B virus. Qualitative – reactive, non-reactive Quantitative – with values (eg. <10mlU/ml) Fig. 12 Percutaneous Umbilical Blood Sampling BIOPHYSICAL SCORING 30 mins observation by UZD Result interpretation 8-18 = normal fetus 6 = chronic asphyxia (repeat procedure after 24 hrs) 4 = abnormal result 2 = ill fetus, terminate pregnancy 5 Markers Non Stress Test (NST) Determines the response of the fetal heart rate to fetal movement @ 28 wks Electronic fetal monitor 2 - 2 or more FHT accleration per movement 1 - <2 accelerations per movement 0 – no acceleration Fetal Breathing 2 – 1 episode/30 mins lasting 30 secs 0 – no episode Amniotic Fluid Index Normal AFI – 5-15 cm water (some books up to 20cm) 2 – fluid filled pocket of 1 cm or more 0 – no amniotic fluid or less than 1 cm in every pocket Polyhydramnios – too much production of Amniotic fluid Intervention: Less fluid intake Oligohydramnios – less production of Amniotic fluid Intervention: increase fluid intake Fetal Body Movement 3 or more discrete movement of lims and body in 30 mins 1 – less than 3 movements 0 – no movements Fetal Heart Tone 2 – 1 or more episodes of active extension with return to felxion of limbs and trunk 1 – slow extension with return flexion HEPATITIS B DETERMINATION SOP; protection against infection CONTRACTION STRESS TEST (CST) Done after 32 weeks AOG Electronic fetal monitor To know if the baby can toleratre contractions Negative – normal, no fetal heart deceleration Positive – abnormal, with deceleration Additional Notes: Similarity between CST and NST is the equipment used which is the Electronic Fetal Monitor (EFM) It is important to know if there’s any FHR deceleration during contraction to determine if the fetus has enough oxygen during contraction/can tolerate uterine contraction FETOSCOPY Direct visualization of the fetus through a scope Is an endoscoopuc prceodure during pregnancy to allow access to the fetus, the amniotic cavity, the umbilical cord, and the fetal side of the placenta Obtain sampe tissues or blood May perform intrauterine fetal surgery FETAL MOVEMENT COUNTING Done after 27 weeks AOG Proof baby is alive Twice daily for 20-30 minutes Normal – 5-6 movements in 20-30 minutes Abnormal – less done 3 movements in 1 hour MEDICAL COMPLICATIONS DURING PREGNANCY CARDIOVASCULAR DISORDERS Pregnancy Increase blood volume 40-50% ( 5-6 L of blood is ejected per minute 7.5 L/min - normal if pregnant Increase cardiac output Decrease BP during first trimester Blood is needed during the first few weeks where fetal development is very fragile Inrease size of ventricular chamber To accommodate increase blood volume and cardiac output 5 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D Downloaded by Modern Day Samuel (moderndaysamuel@gmail.com) lOMoARcPSD|28738202 VENTRICULAR SEPTAL DEFECT (VSD) Left ventricular hypertrophy Pulmonary hypertension Biventricular hypertrophy Fig. 13 Normal Blood Flow LEFT TO RIGHT SHUNTING Deviation between the left and right side of the heart, resulting to compromised oxygenation because of mixture of deoxygenated and oxygenated blood. Fig. 16 VSD PATENT DUCTUS ARTERIOUSUS (PDA) The baby is called “blue baby” Rare Early surgical repair Similar with VSD Fig. 14 Photo of Heart ATRIAL-SEPTAL DEFECT (ASD) Asymptomatic Increase pulmonary blood flow Pulmonary hypertension Fig. 17 VSD RHEUMATIC HEART DISEASE (RHD) Group A Beta hemolytic Streptococcus Inflammatory process Autoimmune disease Scarring valves The treatment for this is an antibiotic SIGNS AND SYMPTOMS OF CARDIAC DISEASES Fig. 15 ASD Shortness of breath Palpitations Orthopnea Difficulty of breathing while lying down Expectoration of blood Cyanosis Murmur Heart enlargement Hypertrophy of ventricles 6 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D Downloaded by Modern Day Samuel (moderndaysamuel@gmail.com) lOMoARcPSD|28738202 FUNCTIONAL CLASSIFICATIONS OF CARDIAC DISEASES CLASS I - Asymptomatic CLASS II - Symptomatic but with normal activities CLASS III - Symptomatic with less than normal activities CLASS IV - Symptomatic and at rest JUDGMENT OF SAFETY PREGNANCY Conception should be preventive if: Conception - ovulation to implantation 1. 2. 3. 4. 5. 6. 7. 8. 9. Severe heart disease Functional classification: Class III-IV History of Heart Failure Pulmonary hypertension Right to left shunting Can lead to fetal distress Severe arrythmia Rheumatic fever Combined valve disease Acute myocarditis MANAGEMENT OF CARDIAC DISEASE Rest Termination of pregnancy by CS Weight reduction 25-35 pounds – ideal total weight gain for pregnant women Prevent infection Digoxin (decreases HR) Diuretics (promotes urination) Antidote: Digoxin Immune Fab NURSING CARE OF CARDIAC DISEASES Vital signs monitoring Proof of any unusualities patient has manifested Provide rest Stress-free and calm environment Emotional support I&O monitoring Urinal – to calibrate urine output Also used to transfer urine from bedpan Proper Nutrition Carry out medical orders REFERENCES I. Notes from: Ma’am Domanais’ and Maam Operario’s Discussion 7 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D Downloaded by Modern Day Samuel (moderndaysamuel@gmail.com)
