Nancy Pares, RN, MSN
Metro Community College
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Apply basic knowledge of healthy maternal
newborn care (recall from PN year)
Describe ethical and legal issues of maternal
newborn nursing, current legislation and
community resources available.
Demonstrate appropriate therapeutic
communication and assessment of high risk
pregnancy.
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Context
◦ Who is involved, what is the setting
◦ What other information is needed
◦ What personal beliefs of the nurse may impact the
situation
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Clarification of the issues
◦ What are the ethical issues
◦ Who should decide the issue
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Identification of alternatives and potential
outcomes
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Ethical reasoning
◦ What ethical theories have bearing on the situation
◦ Should some theories be given greater weight in the
decision making process
◦ What legal or social constraints are factors
◦ What obligations might be present in the role of the
nurse
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Resolution
◦ What is the best action in this situation
◦ What strategy should be used to carry out this
action
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Evaluation
◦ What were the outcomes
◦ Should this same action be used in the future for
similar dilemmas
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Professional Nurse
Certified Registered Nurse
Nurse Practitioner
Clinical Nurse Specialist
Certified Nurse Midwife
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Religion and social beliefs
Presence and influence of the extended
family
Socialization within the ethnic group
Communication patterns
Beliefs and understanding about health and
illness
Permissible physical contact with strangers
education
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Standards of care:
◦ Minimum criteria for competent, proficient, delivery
of nursing care
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Institutional policies
Ethical implications
Scope of practice
◦ Defined by state Nurse Practice Act
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laws
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There was a duty to provide care.
The duty was breached.
Injury occurred.
The breach of duty caused the injury
(proximate cause).
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Divergence between rights of mother and
rights of fetus:
◦ Mother may refuse fetal intervention.
◦ Fetal intervention may be forced on mother.
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Fetal research:
◦ Therapeutic vs. non-therapeutic
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Intrauterine fetal surgery:
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Therapy for anomalies incompatible with life
Health of the mother and fetus is at risk
Surrogate, frozen embryo,
Female circumcision
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Abortion
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Nursing role
◦ Can be performed until point of
viability
◦ After viability, if mother’s health in
jeopardy
◦ Have right to refuse to assist
◦ Responsible for ensuring a qualified
replacement is available
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Infertility
Human stem cells
Cord blood
Maternal refusal for c/del
Maternal refusal for fetal surgery
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Womens’ health standards by Association of
Women’s Health, Obstetric and Neonatal
Nurses (AWHONN)
State Boards
Individual facilities policy
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A holistic interpersonal approach
Adequate documentation
Communication
Updated and realistic policies and procedures
Appropriate delegation
Question deviations from the standar
Follow chain of command
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Transforms research findings into clinical
practice:
◦ Efficiency improvement
◦ Better outcomes
◦ Quality improvement
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Identify vulnerable periods during which
malformations of various organs may occur
and describe the resulting anomalies.
Describe the function and structure of the
placenta during intrauterine life. (review PN
year)
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Mitosis:
◦ Exact copies of original cell
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Meiosis:
◦ Production of new organism
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Deletion
◦ Loss of chromosome material
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Translocation
◦ Misplacement
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Nondisjunction
◦ Chromosomes don’t separate correctly
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Karotype
◦ Chromosomal make up of an individual
Mosaicism
two or more genetically different cell
populations in an individual
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Interphase
Prophase
Metaphase
Anaphase
Telophase
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First division:
◦ Chromosomes replicate, pair, and exchange
information.
◦ Chromosome pairs separate, and cell divides.
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Second division:
◦ Chromatids separate and move to opposite poles.
◦ Cells divide, forming four daughter cells.
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Ovary gives rise to oogonial cells.
Cells develop into oocytes.
Meiosis begins and stops before birth.
Cell division resumes at puberty.
Development of Graafian follicle.
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Production of sperm
First meiotic division:
◦ Primary spermatocyte replicates and divides.
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Second meiotic division:
◦ Secondary spermatocytes replicate and divide.
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Produce four spermatids.
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Uniting sperm and ovum form a zygote
Ova are fertile for 12 to 24 hours
Sperm are fertile for 72 hours
Takes place in the ampulla of fallopian tube
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Capacitation:
◦ Removal of plasma membrane and glycoprotein
coat
◦ Loss of seminal plasma proteins
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Acrosomal reaction:
◦ Release of enzymes
◦ Allows entry through corona radiata
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Zone pellucida blocks additional sperm from
entering
Secondary oocyte completes second meiotic
division
◦ Forms nucleus of ovum
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Nuclei of ovum and sperm unite
Membranes disappear
Chromosomes pair up
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Fraternal: two ova and two sperm
Identical: single fertilized ovum
- Originate at different stages
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Cleavage
Blastomeres form morula
Blastocyst:
- develops into embryonic disc and amnion
Trophoblast:
- develops into chorion
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Occurs 7 to 10 days after fertilization
Blastocyst burrows into endometrium
Endometrium is now called decidua
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Primary germ layers:
◦ Ectoderm
◦ Mesoderm
◦ Endoderm
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Metabolic and nutrient exchange
Maternal portion:
◦ Decidua
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Fetal portion:
◦ Chorionic villi
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Fetal surface covered by amnion
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Chorionic villi form spaces in decidua basalis
Spaces fill with maternal blood.
Chorionic villi differentiate:
◦ Syncytium: outer layer
◦ Cytotrophoblast: inner layer
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Anchoring villi form septa
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Body stalk fuses with embryonic portion of
the placenta
Provides circulatory pathway from chorionic
villi to embryo:
◦ One vein
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Delivers oxygenated blood to fetus:
◦ Two arteries
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Nutrition
Excretion
Fetal respiration
Production of fetal nutrients
Production of hormones
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Beginning development of GI tract
Heart is developing
Somites develop—beginning vertebrae
Heart is beating and circulating blood
Eyes and nose begin to form
Arm and leg buds are present
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Trachea is developed
Liver produces blood cells
Trunk is straighter
Digits develop
Tail begins to recede
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Eyelids are closed
Tooth buds appear
Fetal heart tones can be heard
Genitals are well-differentiated
Urine is produced
Spontaneous movement occurs
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Lanugo begins to develop
Blood vessels are clearly developed
Active movements are present
Fetus makes sucking motions
Swallows amniotic fluid
Produces meconium
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Subcutaneous brown fat appears
Quickening is felt by mother
Nipples appear over mammary glands
Fetal heartbeat is heard by fetoscope
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Eyes are structurally complete
Vernix caseosa covers skin
Alveoli are beginning to form
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Testes begin to descend
Lungs are structurally mature
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Rhythmic breathing movements
Ability to partially control temperature
Bones are fully developed but soft and
flexible
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Increase in subcutaneous fat
Lanugo begins to disappear
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Skin appears polished
Lanugo has disappeared except in upper
arms and shoulders
Hair is now coarse and approximately 1 inch
in length
Fetus is flexed
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Quality of sperm or ovum
Genetic code
Adequacy of intrauterine environment
Teratogens
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Maternal effects:
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Malnutrition
Bone-marrow suppression
Increased incidence of infections
Liver disease
Neonatal effects:
◦ Fetal alcohol spectrum disorders (FASD)
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Seizures and hallucinations
Pulmonary edema
Respiratory failure
Cardiac problems
Spontaneous first trimester abortion, abruptio
placentae, intrauterine growth restriction
(IUGR), preterm birth, and stillbirth
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Decreased birth weight and head
circumference
Feeding difficulties
Neonatal effects from breast milk:
◦ Extreme irritability
◦ Vomiting and diarrhea
◦ Dilated pupils and apnea
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Maternal effects:
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Poor nutrition and iron-deficiency anemia
Preeclampsia-eclampsia
Breech position
Abnormal placental implantation
Abruptio placentae
Preterm labor
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Maternal effects:
◦ Premature rupture of the membranes (PROM)
◦ Meconium staining
◦ Higher incidence of STIs and HIV
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Fetal effects:
◦ IUGR
◦ Withdrawal symptoms after birth
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Marijuana: difficult to evaluate, no known
teratogenic effects
PCP - maternal overdose or a psychotic
response
MDMA (Ecstasy) - long-term impaired
memory and learning
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Identify tests used to detect abnormalities,
fetal well being and infertility management.
Discuss age related considerations of
pregnancy.
Explain the nursing process as it relates to
maternal fetal medical conditions.
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Favorable cervical mucus
Clear passage between cervix and tubes
Patent tubes with normal motility
Ovulation and release of ova
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No obstruction between ovary and tubes
Endometrial preparation
Adequate reproductive hormones
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Normal semen analysis
Unobstructed genital tract
Normal genital tract secretions
Ejaculated spermatozoa deposited at the
cervix
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Ovulation
Cervix
Uterine structures
Tubal patency
Semen analysis
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Ovulatory:
◦ Pharmacologic treatment
◦ Donor oocytes
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Cervical:
◦ THI, IVF, GIFT
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Uterine/Tubal:
◦ IVF, GIFT
◦ Donor oocytes or gestational carrier
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Sperm:
◦ THI, IVF, GIFT
◦ Micromanipulation
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Marriage may be stressed
Relationship affected by intrusiveness
Guilt
Frustration
Anger
Shame
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Loss of control
Feelings of reduced competency and
defectiveness
Loss of status and ambiguity as a couple
A sense of social stigma
Stress on the personal and sexual
relationship
A strained relationship with healthcare
providers
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Counselor
Educator
Advocate
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Maternal age 35 or over
Family history:
◦ Known or suspected Mendelian genetic disorder
◦ Birth defects and/or mental retardation
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Previous pregnancies:
◦ Previous child with chromosomal anomaly
◦ Previous child with metabolic disorder
◦ Two or more first trimester spontaneous abortions
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Parental genetics:
◦ Couples with a balanced translocation
◦ Couples who are carriers for a metabolic disorder
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Abnormal MSAFP
Women with teratogenic risk
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Multigenerational
50% chance of passing on the gene
Males and females equally affected
Varying degrees of presentation
Diseases
◦ Achondroplasia
◦ Marfans
◦ Neurofibromotosis
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Achondroplasia
◦ Most common dwarfism, lifespan and IQ WNL
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Marfans
◦ Connective tissue disorder, triad of ocular, skeletal
and CV alterations
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Neurofibromotosis (Von Recklinhausen)
◦ Soft tumor development of peripheral nerves
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Carrier parents
25% chance of passing on abnormal gene
25% chance of an affected child
If child is clinically normal, 50% chance child
is carrier
Males and females equally affected
Diseases: CF, Sickle Cell, PKU, Tay Sachs
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No male-to-male transmission
50% chance carrier mother will pass the
abnormal gene to sons (affected)
50% chance carrier mother will pass the
abnormal gene to daughters (carrier)
Diseases: Hemophilia A, Duchennes MD,
Trisomies, Klinefelters, Turner’s Cri du chat,
Fragile X
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Genetic ultrasound
Genetic amniocentesis
Chorionic villus sampling
Percutaneous umbilical blood sampling
MSAFP
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Educate about tests
Provide support
Refer for counseling
Resource during and after counseling
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Identify the maternal fetal effects of TORCH
(toxoplasmosis, other, rubella,
cytomegalovirus, herpes) infections and the
corresponding nursing interventions.
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Toxoplasmosis
Rubella
Cytomegalovirus
Herpes simplex virus
Group B streptococcus
Human B-19 parvovirus
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Retinochoroiditis
Convulsions
Coma
Microcephaly
Hydrocephalus
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Congenital cataracts
Sensorineural deafness
Congenital heart defects
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Neurologic complications
Anemia
Hyperbilirubinemia
Thrombocytopenia
Hepatosplenomegaly
SGA
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Preterm labor
Intrauterine growth restriction
Neonatal infection
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Respiratory distress or pneumonia
Apnea
Shock
Meningitis
Long-term neurologic complications
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Spontaneous abortion
Fetal hydrops
Stillbirth
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Discuss pathophysiology, treatment and
nursing interventions for pregnant women
with:
◦ Cardiac Disease, Chorioamnionitis, Gestational
trophoblastic disease, diabetes, Rh sensitivity,
pregnancy induced hypertension and HELLP
syndrome, HIV, hyperemesis gravidarium .
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Endocrine disorder of carbohydrate
metabolism
Results from inadequate production or
utilization of insulin
Cellular and extracellular dehydration
Breakdown of fats and proteins for energy
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Carbohydrate intolerance of variable severity
Causes:
◦ An unidentified preexistent disease
◦ The effect of pregnancy on a compensated
metabolic abnormality
◦ A consequence of altered metabolism from
changing hormonal levels
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Early pregnancy:
◦ Increased insulin production and tissue sensitivity
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Second half of pregnancy:
◦ Increased peripheral resistance to insulin
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Hydramnios
Preeclampsia-eclampsia
Ketoacidosis
Dystocia
Increased susceptibility to infections
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Perinatal mortality
Congenital anomalies
Macrosomia
IUGR
RDS
Polycythemia
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Hyperbilirubinemia
Hypocalcemia
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Assess risk at first visit:
◦ Low risk - screen at 24 to 28 weeks
◦ High risk - screen as early as feasible
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Age over 40
Family history of diabetes in a first-degree
relative
Prior macrosomic, malformed, or stillborn
infant
Obesity
Hypertension
Glucosuria
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One-hour glucose tolerance test:
◦ Level greater than 130-140 mg/dl requires further
testing
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3-hour glucose tolerance test:
◦ GDM diagnosed if 2 levels are exceeded
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Maintain a physiologic equilibrium of insulin
availability and glucose utilization
Ensure an optimally healthy mother and
newborn
Treatment:
◦ Diet therapy and exercise
◦ Glucose monitoring
◦ Insulin therapy
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AFP
Fetal activity monitoring
NST
Biophysical profile
Ultrasound
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Assessment of glucose
Nutrition counseling
Education about the disease process and
management
Education about glucose monitoring and
insulin administration
Assessment of the fetus
Support
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Maternal complications:
◦ Susceptible to infection
◦ May tire easily
◦ Increased chance of preeclampsia and postpartal
hemorrhage
◦ Tolerates poorly even minimal blood loss during
birth
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Fetal complications:
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Low birth weight
Prematurity
Stillbirth
Neonatal death
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Prevention and treatment:
◦ Prevention - at least 27 mg of iron daily
◦ Treatment - 60-120 mg of iron daily
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Maternal complications:
◦ Nausea, vomiting, and anorexia
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Fetal complications:
◦ Neural tube defects
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Prevention - 4 mg folic acid daily
Treatment - 1 mg folic acid daily plus iron
supplements
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Maternal complications:
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Vaso-occlusive crisis
Infections
Congestive heart failure
Renal failure
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Fetal complications include fetal death,
prematurity, and IUGR.
Treatment:
◦ Folic acid
◦ Prompt treatment of infections
◦ Prompt treatment of vaso-occlusive crisis
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Treatment:
◦ Folic acid
◦ Transfusion
◦ Chelation
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Asymptomatic women - pregnancy has no
effect
Symptomatic with low CD4 count - pregnancy
accelerates the disease
Zidovudine (ZDV) therapy diminishes risk of
transmission to fetus
Transmitted through breast milk
Half of all neonatal infections occurs during
labor and birth
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Intrapartal or postpartal hemorrhage
Postpartal infection
Poor wound healing
Infections of the genitourinary tract
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Infants will often have a positive antibody
titer
Infected infants are usually asymptomatic but
are likely to be:
◦ Premature
◦ Low birth weight
◦ Small for gestational age (SGA)
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Counsel about implications of diagnosis on
pregnancy:
◦ Antiretroviral therapy
◦ Fetal testing
◦ Cesarean birth
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Congenital heart disease
Marfan syndrome
Peripartum cardiomyopathy
Eisenmenger syndrome
Mitral valve prolapse
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Rheumatoid arthritis
Epilepsy
Hepatitis B
Hyperthyroidism
Hypothyroidism
Maternal phenylketonuria
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Multiple sclerosis
Systemic lupus erythematosus
Tuberculosis
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Tubal damage
Previous pelvic or tubal surgery
Endometriosis
Previous ectopic pregnancy
Presence of an IUD
High levels of progesterone
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Congenital anomalies of the tube
Use of ovulation-inducing drugs
Primary infertility
Smoking
Advanced maternal age
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Methotrexate
Surgery
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Assess the appearance and amount of vaginal
bleeding
Monitors vital signs
Assess the woman’s emotional status and
coping abilities
Evaluate the couple’s informational needs.
Provide post-operative care
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Vaginal bleeding
Anemia
Passing of hydropic vesicles
Uterine enlargement greater than expected
for gestational age
Absence of fetal heart sounds
Elevated hCG
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Low levels of MSAFP
Hyperemesis gravidarum
Preeclampsia
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D&C
Possible hysterectomy
Careful follow-up
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Monitor vital signs
Monitor vaginal bleeding
Assess abdominal pain
Assess the woman’s emotional state and
coping ability
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Control vomiting
Correct dehydration
Restore electrolyte balance
Maintain adequate nutrition
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Assess the amount and character of further
emesis
Assess intake and output and weight.
Assess fetal heart rate
Assess maternal vital signs
Observe for evidence of jaundice or bleeding
Assess the woman’s emotional state
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Preeclampsia-eclampsia
Chronic hypertension
Chronic hypertension with superimposed
preeclampsia
Gestational hypertension
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Maternal vasospasm
Decreased perfusion to virtually all organs
Decrease in plasma volume
Activation of the coagulation cascade
Alterations in glomerular capillary
endothelium
Edema
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Increased viscosity of the blood
Hyperreflexia
Headache
Subcapsular hematoma of the liver
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Small for gestational age
Fetal hypoxia
Death related to abruption
Prematurity
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Monitoring for signs and symptoms of
worsening condition
Fetal movement counts
Frequent rest in the left lateral position
Monitoring of blood pressure, weight, and
urine protein daily
NST
Laboratory testing
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Bed rest
High-protein, moderate-sodium diet
Treatment with magnesium sulfate
Corticosteroids
Fluid and electrolyte replacement
Antihypertensive therapy
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Scotomata
Blurred vision
Epigastric pain
Vomiting
Persistent or severe headache
Neurologic hyperactivity
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Pulmonary edema
Cyanosis
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Assess characteristics of seizure
Assess status of the fetus
Assess for signs of placental abruption
Maintain airway and oxygenation
Position on side to avoid aspiration
Suction to keep the airway clear
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To prevent injury, raise padded side rails
Administer magnesium sulfate
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Hemolysis, elevated liver enzymes, low
platelets
◦ Hypertension and proteinuria may or may not be
present
◦ 90% present with symptoms before 36 wks gest.
◦ All with HELLP should deliver
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Rh – mother, Rh + fetus
Maternal IgG antibodies produced
Hemolysis of fetal red blood cells
Rapid production of erythroblasts
Hyperbilirubinemia
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After
After
After
After
After
birth of an Rh+ infant
spontaneous or induced abortion
ectopic pregnancy
invasive procedures during pregnancy
maternal trauma
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Mom is type O
Infant is type A or B
Maternal serum antibodies are present in
serum
Hemolysis of fetal red blood cells
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Incidence of spontaneous abortion is
increased in first trimester
Insert nasogastric tube prior to surgery
Insert indwelling catheter
Encourage patient to use support stockings
Assess fetal heart tones
Position to maximize utero-placental
circulation
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Greater volume of blood loss before signs of
shock
More susceptible to hypoxemia with apnea
Increased risk of thrombosis
DIC
Traumatic separation of placenta
Premature labor
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Psychological distress
Loss of pregnancy
Preterm labor
Low-birth-weight infants
Fetal death
Increased risk of STIs