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Mother Baby Class Notes Module 3 Conception- union of the egg and sperm Fertilization – takes place in the outer ⅓ of the fallopian tube, called ampulla Implantation- 6 to 10 days after conception Embryo- 15 days to 8 weeks after conception this is what the egg is considered Fetus- 9 weeks up until delivery this is what its considered Viability- the baby’s ability to live without the mom-- the baby is viable at about 24 weeks Amniotic membrane contains chorian outside of the placenta Chorion (outer membrane) develops from trophoblast. Contains chorionic villi and becomes the fetal side of placenta. Amnion develops from interior cell blastocyst. Embryo draws amnion around itself, forming a fluid-filled sac covering the umbilical cord and the chorion on the fetal side of placenta Amniotic fluid- increases weekly, usually about 800-1000 mL of fluid surrounding the baby (once baby is term), the fluid protects the baby from infection, provides support/cushion and warmth, and provides a means of fluid intake, helps maintain babies' temp. Oligohydramnios- 500 ml or less of amniotic fluid, can cause renal abnormalities and inadequate placental blood flow Polyhydramnios or hydramnios- over 2000 mL of amniotic fluid- GI malfunction, digestive malfunctions, or CNS malfunctions.
Placenta- thick disc shaped substance, 2 sides of a placenta: the shiny side shiny shoals, is the fetal side, the dirty side is going to the mom the diary of the pregnancy, provides O2, nutrients, meds, virus’ and infections can pass through the placenta Umbilical cord covered with Wharton's Jelly to prevent cord compression. Cord around the neck is called a nuchal cord. Umbilical cord- 2 arteries and 1 vein, vein carries oxygenated blood to fetus from placenta, arteries carry deoxygenated blood and gets rid of all waste products by transporting in the mom’s system.
behind. Examples -
- only able to drink hot liquids for a period of time, then cold liquids for a period of time for a yin and yang
- Colostrum is bad for the baby so they do not feed the baby right away.
- African americans put a penny over the navel
- Staying in the house for a certain number of weeks after having a baby.
- Leaving umbilical cord attached. Maternal tasks of pregnancy - accepting pregnancy and establishing relationships with the fetus. All of her decisions must include the baby. Separating the fetus from self is when she delivers the baby and see’s baby in the crib.
Paternal tasks of pregnancy- accepting pregnancy, establishing a relationship with the fetus, becoming involved with pregnancy, adjusting to changes in self and changing relationships. Mother should take father to appointments, exercise together, same diet, etc.. to help father adjust to pregnancy as well. Adaptation of the family - siblings. Grandparents and other extended members. Incorporate kids- let them feel the baby move, take kids to appointments to find out what the baby is, allow them to help name the baby, etc. For grandparents - they usually make themselves involved. Give them roles and keep them informed with pregnancy. Let them be the babysitter. Physiologic changes in pregnancy: Was the pregnancy unwanted? Adolescent pregnancy could cause school interrupted, early marriage, divorce, unemployment, care of newborn, and prenatal care. Diagnosis of Pregnancy: human chorionic gonadotropin: can be seen 6 to 11 days after conception.
- Presumptive signs- signs that are felt by the woman. Amenorrhea, breast changs, fatigue.
- Probable signs- felt or seen by the examiner. Hegar's sign (uterus feels softened), Chadwick's sign (bluish color of cervix),. Ballottement (being able to bounce the uterus and feeling it rebound) and pregnancy tests (watch for false positives) diuretics can cause a false negative.
- Positive signs are hearing FHR and seeing the fetus on ultrasound and palpating the fetal outline. Nagele’s Rule- used to calculate possible due date-- add 7 days to the first day of the LMP, count backwards 3 months and add 1 year if needed. EX: LMP: June 9th 2014. EDD: 03/16/ Tips for early pregnancy -
- Avoid X-rays, live vaccinations, meds, alcohol, tobacco, and occupational hazards
- Seek early prenatal care
- Allow for diagnosis and intervention of ectopic pregnancy - outside the uterus
- Abortion is safest in first 12 weeks Nutrition in Pregnancy:
- Improving one’s diet during pregnancy cannot overcome previous deficiencies. A good diet reduces risks of maternal complications, helps
- Obese 11-20 pounds, overweight 15-25 pounds, and underweight 28-40 pounds. Maternal pre-pregnancy weight is a predictor of neonatal body composition.
- Obese clients need folate and B vitamins. These women have a BMI >25. They have risks for gestational diabetes, preeclampsia, infection, preterm labor, VTE, cesarean birth, prolonged labor, stillbirth, and PPH.
- Eating disorders are associated with abortion, stillbirth, hypertension, cesarean birth, low birth weight, fetal anomalies, low Apgar scores, increased risk for hemorrhage, and birth trauma. Also have a higher risk for postpartum depression. Trimesters:
- 1st- 1 to 13 weeks
- 2nd- 14 to 27 weeks
- 3rd- 28 to 40 weeks Initial Prenatal Visit- first visit:
- Health History - consists of demographic data, a detailed health history, present health, menstrual/obstetric history, and present and past pregnancy symptoms and problems.
- Psychosocial Assessment - consists of the woman and her partner’s attitudes towards the pregnancy, emotional, and financial impact on the family and the expectations of the woman and those involved.
- Physical exam - VS (baseline determined at first visit. BP is lowest early in pregnancy. Is considered abnormal if rises 30/15, ht, wt (pre-pregnant and pregnant). Normal weight gain is 10 lbs. at 20 weeks, gain 25-35 lbs by term, approx 2.2 lbs per visit (if more, assess diet, edema) and a systems’ assessment.
- Laboratory tests include a Pap smear, vaginal cultures, urine specimen (protein is not normally present). Assess for edema, check for preeclampsia and kidney disease. Recommended to test for diabetes if not already a diabetic. Ketones indicate burning fat, need to assess diet, blood could indicate UTI or kidney disease). Blood studies (sickle cell, Hgb & Hct, Rh) EDD) also determined. Determine blood group and Rh. Many HCPs do HIV testing, GC, and VDRL or RPR to see if she has syphilis. CDC suggests chlamydia screening for all pregnant women (retest during third trimester). Prenatal Visits-
- 1-28 weeks: every 4 weeks
- 29- 35 weeks: every 2 weeks
- 35 weeks until delivery: every week Fundal height should be equivalent to number of weeks that mother is pregnant
Transvaginal ultrasound confirms pregnancy, confirms gestational age and rule out ectopic pregnancy. At 16 weeks discuss triple or quad screen. This is a blood test that measures hCG, estriol and AFP. Used to r/o or screen clients at risk for Down syndrome and open neural tube defects. Maternal21™ or Harmony™ – screening test O’Sullivan test – normal is ≤130 mg. If abnormal, the client has a 3-hour GTT. Give CHO load 3 days before the 3-hour GTT. For an obese, pregnant client the screening occurs at 20 weeks. No fasting required for O’Sullivan. If mom is already diabetic, glucose is checked on first visit to help manage the sugar levels.
patterns. We want to see 3 contractions within 10 minutes lasting 40-60 seconds. FHR should not decelerate (decrease in heart rate)
- BPP (Biophysical profile) - provides a score using 5 parameters (NST, gross body movement, fine body movement, fetal breathing activity, and amniotic fluid volume). Acceptable score is 8-10. If a score of 6, repeat within 24 hours. If a score of 4 or less, plan delivery.
- Kick counts - client lies in comfortable position for approximately 30 minutes. May be done BID. Counts how many times the fetus moves within that time frame. Should get at
least 4. If not, extend to an hour; should get 10 with the woman’s drinking 8 ounces of water. Want 10 movements in 2 hours.
- NIPD (noninvasive prenatal diagnosis)– 10/11 introduced this test to screen for Down syndrome as early as 7 weeks by using a sample of maternal blood.
- Nuchal translucency – ACOG recommends. Done at 11-14 weeks. Determines Down syndrome, Trisomy 18, Turners, and heart defects. ASSESSMENT OF FETAL well being for High risk pregnancy:
- Percutaneous umbilical blood sampling- commonly called cordocentesis. Fetal blood is collected from the umbilical cord by passing a fetoscope. Done for more advanced testing, genetic karyotyping
- Chorionic villus sampling- assessing portion of the developing placenta, aspiration through syringe. Performed at 10-13 weeks gestation. Done for more advanced testing of fetal anomalies…..genetic testing
- Maternal serum alpha- fetoprotein (MSAFP)- screening for neural tube defect spine, spinal cord, brain Signs & symptoms to report: Vaginal bleeding, dizziness (possible compression of vena cava-- lay on side), preterm labor symptoms, rupture of membranes (water breaks-- increased risk for infection-- go to hospital), preeclampsia/eclampsia (pre: high blood pressure-- excessive swelling in hands or feet) Eclampsia: (seizures), change in fetal movement. Lifestyle threats to pregnancy:
- Smoking can contribute to low birth weight, IUGR (intrauterine growth restrictions) and preterm labor. Also, SAB (spontaneous abortion), bleeding, abruptio placentae and placenta previa. In the fetus can increase the chance of SIDS.
- Alcohol and drug abuse can cause fetal alcohol syndrome - fetal blood level > maternal, drug withdrawal (irritability, agitation, hypertonicity, feeding disorders, diarrhea, dehydration. Sudden withdrawal can cause fetal death, addiction and is a risk factor for poor compliance to prenatal care. Clients who use amphetamines are more likely to have preterm births, an SGA newborn, or low birth weight newborn.
- Family violence can make a woman feel helpless, depressed, or trapped. Abusive men often abuse children also. The women are also in danger if they threaten to leave and end the relationship. Domestic violence increases 60% during pregnancy.
- Obesity is a threat because of spontaneous AB, gestational HTN, gestational diabetes, postpartum hemorrhage, and sleep apnea.
Between 14 and 20 weeks the pulse increases about 10 to 20 BPM. Palpitations may occur. Cardiac rhythm may be disturbed. There is hypertrophy of the left ventricle. The heart shifts position in 3 ways (upward, closer to anterior wall, and PMI towards axillary area). BP varies with age. During 1st trimester BP usually remains at the prepregnancy level. During the second trimester both SBP and DBP decrease. This is due to the peripheral vasodilation caused by hormones. Blood volume increases 40 -50%. This takes place in order to give blood flow to the placenta and fetus. Increased cardiac output (6-8 liters/minute). Decreased SVR.
- RESP -The diaphragm displaced upward by the enlarging uterus. However, the increased levels of estrogen cause the ligaments of the rib cage to relax, permitting the chest to expand. The upper airway is more vascular because of the increase of estrogen and may lead to nosebleeds. This increase in vascularity may also affect the eustachian tubes as well as the tympanic membranes and give rise to Sx of impaired hearing, fullness in the ears, or even earaches. The pregnant woman breathes deeper, but her respiratory rate will be slightly elevated (10 breaths more). Normal blood gas values: pH 7.40-7.45; PaO 104-108; PaCO2 27-32; HCO3 18-21 (She is in compensated respiratory alkalosis.)
- RENAL: increased GFR. Ureters dilate and elongate. Frequent urination initially results from increased bladder sensitivity and later the compression of the bladder. Fluid retention may occur. Body may store 6-8 liters. Side-lying position with elevated feet helps this. Decreased level of bladder tone under the influence of estrogen.
- INTEGUMENTARY: changes from hormones (linea nigra and striae gravidarum). May be due to adrenocorticosteroids. May be genetic. Dark near term; will never go away but will fade to silvery color.
- MUSCULOSKELETAL changes – waddle; large, distended abdomen gives pelvis a forward tilt, and some relaxation of pelvic joints. During the 3rd trimester rectus abdominis muscles begin to separate in preparation for labor and birth.
- GI - may be a fluctuation in appetite. Early pregnancy some have nausea with/without vomiting. This is due to increasing levels of hCG or altered carbohydrate metabolism. Endocrine changes are necessary for normal fetal growth and the maintenance of pregnancy. Their sources are hormones.
- REPRODUCTIVE SYSTEM i- greatly changed. Uterus: at 7 weeks is size of hen egg; at 10 weeks size of orange;;12 weeks grapefruit; during 2nd trimester rises out of the pelvis; and the pregnancy may begin to show around week 14. Uterine measurement
and growth are determined by fundal height. Usually equal to gestational age. Uterus may contract by 4th month (Braxton Hicks contractions). Cervix will soften. Leukorrhea may occur; increased vascularity may cause bluish discoloration. Breasts begin to enlarge; areola may enlarge; breasts may become tender.
- Most pregnant women are in constant stress Nulliparous- never been pregnant, never given birth Primigravida- 1st time giving birth Multigravida- given birth two or more times Gestational Hypertension- before 20 weeks and resolves before 12 weeks postpartum S/S:
- Absence of protein in the urine,
- sudden weight gain,
- Premature birth or delivery
- Death Eclampsia- includes seizures and coma
Preeclampsia:
- 300 mg or more of protein in the urine seen with a 24 hour urine collection-- spillage of protein due to intracellular involvement
- Increased creatinine levels
- Appears without a warning
- Develops after 20 or more weeks
- HTN & Proteinuria
- Blood pressure range: 160/
- Platelet levels decreased
- Uric acid elevated
- BUN elevated
- AST & ALT elevated Nursing interventions:
- Regular diet- no salt or fluid restrictions
- Consistent BP readings
- Daily weight checks
- Bed rest
- Labetalol
- Hydralazine (po or IM)
- Mag sulfate - patient will be in the hospital-- used to reduce BP & prevent seizures by causing the body to relax
- Mag is given to decrease the seizure threshold!
- Mag excreted out of kidneys
- Assessment- urine output, DTR’s to make sure they are not getting too much mag.
- Lung sounds.
- Mag Bolus loading dose given: 4 to 6 gram dose over 30 minutes & 2- grams per hour for maintenance dose. Therapeutic range is 6 to 8.
- Mag Toxicity:
- Decreased DTR”s
- Decreased urine output
- Decreased Respirations
- Decreased or diminished LOC
- Hypotension
- Must assess every hour:
- Lung sounds
- DTR’s
- Urine output Antidote for mag: calcium gluconate Nursing interventions:
- Risk of seizures
- Seizure precautions:
- Pad rails
- Bite block
- Suction at bedside The only cure for preeclampsia is delivery of the fetus and placenta. Medication can lower blood pressure and thus reduce the risk of stroke in the mother, but these treatments do not improve the underlying abnormalities in the placenta and thus does not prevent progression of the disease. The management of pregnancies complicated by preeclampsia depends on the
and effacement (thinning) of the cervix, and the fetus's condition. In most situations, vaginal delivery is possible. Oxytocin (Pitocin) is given intravenously to induce labor (stimulate the uterus to contract). If labor does not progress, or if complications develop that require the fetus to be delivered quickly, a cesarean birth may be indicated Use betamethasone to mature baby’s lungs- given in 2 doses 24 hours apart Misc Information:
- Avoid diuretics
- Monitor for edema
- Daily weight should be recorded
- Evaluate Deep tendon reflexes especially if the patient is receiving magnesium HELLP -Hemolysis Elevated liver Enzymes, Low Platelet count S/S:
- Progression of Preeclampsia
- Hemolysis (breaking down red blood cells), Elevated Liver Enzymes (causing liver damage), Low Platelet count (as low as 20,000)
- Headache
- Nausea/Vomiting
- Abdominal or chest tenderness and upper right side pain (from liver distention)-- epigastric pain
- Shoulder pain or pain when breathing deeply
- Bleeding!
- Bruising
- Changes in vision
- Swelling
- Fatigue
- Extreme weight gain Nursing Interventions:
- Bed rest and admission into a medical facility to be monitored closely.
- -Corticosteroid- betamethasone (to help babies lungs develop more rapidly)
- -Magnesium Sulfate (tto help prevent seizures)
- -Blood transfusion if platelet count gets too low.
- -High BP
- -Protein in urine Pt education:
- Risk of fetal morbidity and mortality for future
- Trust yourself when something “just doesn’t feel right”
- Know your warning signs and report them immediately
- Have regular prenatal visits Misc information:
- Complicates 10% of pregnancies with severe preeclampsia
- -Life threatening
- -May require critical care admission
- -Requires immediate delivery
Hemorrhagic Complications -(Type of Abortion) (Please include types): S/S:
