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Exam 1 Study Guide NUR 346 MATERNAL NEWBORN NURSING
1. Goal of maternal newborn nursing: a. A safe and satisfying experience for the mother, her family, and her baby. 2. Nursing Roles in Women’s Health: a. RNs work as labor nurses, mother-baby nurses, lactation consultants (help teach breastfeeding), clinic nurses, newborn nursery nurses, home health nurses, NICU nurses and gynecology nurses b. RNCs are RNs who have demonstrated clinical expertise in a field and are certified by a national organization c. Nurse Practitioners are usually Master’s prepared nurses who function as advanced practice nurses. NPs usually focus on ambulatory nursing. Women’s Health NPs or Family NPs are examples. Neonatal NPs work in newborn nurseries and NICUs. NPs perform H&Ps, order diagnostic tests and procedures. d. Certified Nurse Midwives function similarly to NPs but also perform deliveries and care for newborns e. Clinical Nurse Specialists have Master’s degrees and specialized knowledge and competence in a specific clinical area 3. Family Centered Childbirth a. Provision of safe, quality nursing care that recognizes, focuses on and adapts to the physical and psychosocial needs of the pregnant woman, her family and her newborn. b. Fosters family unity and promotes and protects the physiologic well-being of the mother and newborn. c. Fathers, siblings, grandparents, friends encouraged to participate in the birth process d. Families make choices based on their desires. These may include having a physician or midwife attend their births or whether to deliver in a hospital, birth center or at home e. Hospitals now have both Labor & Delivery (L&D) rooms but also Labor, Delivery, Postpartum (LDRP) suites f. The mom dictates who is in the room and who is considered family 4. Philosophy of Family-centered maternal/Newborn Nursing a. Pregnancy and childbirth are usually normal healthy events within the family. b. Childbirth affects the whole family and marks the beginning of a new set of important relationships. c. Families are able to make decisions about care if given the proper information. d. A maternal/newborn nurse serves as an advocate for the rights of all family members, including the fetus. e. Personal, cultural, and religious attitudes influence the meaning of pregnancy and birth within the family. f. Promoting health through role modeling, teaching, and counseling is important to the future health of the community in which the family lives g. Advocate for pt desires and preferences: cultural etc 5. Important Features of Family Centered MNN a. Prenatal and parent education classes. b. Family participation in all aspects of pregnancy & birth. c. Presence of support person for complicated births or cesarean sections d. Use of homelike birth settings. e. Flexible policies regarding routine procedures. f. Flexible rooming in policies. g. Early extended parent-newborn contact. h. Family involvement in care of the mother and newborn. i. Early post birth discharge with close follow up. j. Nontraditional labor and birth settings k. Single room maternity systems which may be called LDR or LDRP. 6. Culturally Competent Care a. Religion/social beliefs b. Presence of extended family c. Communication patterns d. Beliefs and understanding about concepts of health and illness e. Beliefs about propriety of physical contact with strangers f. Education 7. Legal Considerations a. Scope of practice defined as limits of nursing practice as set forth in state statutes b. Health maintenance and disease prevention c. Expanded practice roles include planning care, diagnosis, prescription privileges 8. Standards of Nursing Care a. Establish minimum criteria for competent, proficient delivery of nursing care b. Designed to protect the public and used to judge quality of care provided
c. Legal interpretation of actions within standard of care is based on what a reasonably prudent nurse with similar education and experience would do in similar circumstances d. ANA, AWHONN help define e. Nurse who fails to meet appropriate standards of care may be subject to allegations of negligence or malpractice
9. AWHONN Standards of Care a. Comprehensive nursing care of women and their infants focuses on assisting individuals and families to achieve their optimal health. b. Health education is an integral aspect of comprehensive nursing care, Health teaching focuses on health promotion, maintenance, and restoration. c. The qualifications of personnel authorized to provide care are delineated. The scope of practice is clarified in written policies, procedures, and protocols. d. The nurse must be clinically competent to provide comprehensive care for the mother and newborn. The nurse is legally accountable and responsible for the care given. e. Practice settings must have sufficient numbers of qualified nursing personnel to meet patient care needs. f. Ethical principles guide the clinical judgment of nurses caring for mothers and infants. g. Research and research findings are used to improve client outcomes. h. Systematic evaluation using specific clinical indicators is done to ensure quality of care 10. Informed Consent= Shared Decision Making a. Protects patient right to autonomy and self-determination b. No action may be taken without that person’s consent c. Usually consent obtained by physician or midwife; RNs may witness client’s signature giving consent d. If nurse determines that patient doesn’t understand procedure or risk, RN must notify MD e. In most states, pregnant teenagers are considered emancipated and may give consent for herself f. Refusal of treatment, medication, procedure requires signed form releasing provider and hospital from liability. Jehovah’s Witness patient may refuse blood transfusions or Rhogam 11. Pelvic Exam Consent a. July 1, 2020 Florida statute to require written consent for any pelvic exam. 12. Right to Privacy a. Right of person to keep person and property free from public scrutiny b. Avoid unnecessary exposure of women’s body c. Avoid discussing her care with people not involved in her care
- Special Ethical Issues in Maternity Care a. Maternal-Fetal conflict b. Abortion c. Intrauterine fetal surgery d. Reproductive Assistance e. Embryonic Stem Cell Research f. Surrogate Childbearing g. Genetically designed babies h. Cord Blood Banking i. Micropreemies j. Drug addiction 14. History of Childbirth a. The process of labor and birth unchanged over thousands of years b. Traditionally births have been domain of women c. Family members, birth attendants, midwives d. During Middle Ages and Renaissance, physicians claimed responsibility for childbirth and moved births to asylums and hospitals; forceps developed e. Poor sanitation and poor hand washing led to increase in childbed fever f. During 1800s many women in US and Europe still preferred home births g. Use of Chloroform and Twilight sleep (narcotics, amnesiacs) brought women into hospitals h. Birth became hospital based again but poor sucking, feeding of infants from drugs, sleepy, drugged mothers made breastfeeding difficult i. 1970s saw routine use of fetal monitoring but also a trend toward father participation, natural methods of pain relief, family centered care and home environments in the labor room 15. Statistics in Maternal-Newborn Nursing a. Birth Rate- number of live births per 1000 people b. Infant mortality rate-number of deaths of infants under 1 year of age per 1000 live births c. Neonatal mortality rate- number of deaths of infants less than 28 days of age per 1000 live births d. Fetal death is death in utero at 20 weeks or more gestation e. Perinatal mortality rate- includes both neonatal deaths and fetal deaths per 1000 live births f. US statistics 2020
19. Global Statistics a. Between 250,00 and 343,000 women are estimated to die each year from complications associated with pregnancy and childbirth. b. Ninety-nine per cent of these deaths occur in the developing world where most women’s lives are restricted by illiteracy, poor education and poverty. c. For every woman who dies in childbirth, around 20 more suffer injury, infection or disease – that’s a total of some 10 million women each year. d. Fewer than 50% of all births in developing countries take place with the help of a skilled birth attendant. e. A child whose mother dies during childbirth is 3-10 times more likely to die before his or her second birthday. f. Spacing births two or more years apart significantly reduces the risk of maternal and newborn death. g. In the developed world, a woman's lifetime risk of dying during or following pregnancy is one in 4,300 but in Sub- Saharan Africa that risk is one in 31. h. Some 222 million women who would prefer to delay or avoid pregnancy lack access to, or do not use, safe and effective contraception. i. Each year, more than 50 million women give birth at home without the help of a trained professional. 20. Cesarean Birth a. 1/3 of children in the US are born by c-section. 31.9% b. The c-section rate increased 50% over the past 10 years. c. 1965 C/S rate was 4.5% 21. NTSV Cesarean Birth Rate a. Nulliparous, Term, Singleton, Vertex b. #3. Florida c. Overall C-Section Rate: 36.5% d. Low-Risk C-Section Rate: 31% e. Healthy People 2020 target was 23.9 percent. 22. Family a. U.S. Census Bureau - a family is a group of two people or more related by birth, marriage, or adoption and residing together b. Family Types: i. Nuclear: couple with children ii. Dual career: both parents have jobs iii. Childless: just a couple no children iv. Extended: includes grandparents, uncles, aunts and other relatives who live nearby or in same house v. Extended kin network: extended families with several generations vi. Single parent: one parent with children vii. Stepfamily: family formed from a remarriage and divorce viii. Binuclear: large, interconnected family, with one household headed by the ex-wife and the other household headed by the ex-husband, with the child being a member of both. ix. Nonmarital: only related to one adult but have established child-parent relationships with both x. Gay and Lesbian: two moms or two dads c. Eight Stage Family Life Cycle (Duvall)
Reproductive Anatomy and Physiology and Conception Chapter 3
1. External Genitalia a. Mons pubis-mound of subcutaneous fatty tissue b. Labia Majora-outer folds of pigmented skin covered by hair follicles- protection of other structures c. Labia Minora-inner folds of skin that converge near the anus- form forchette d. Clitoris-covered by clitoral hood or prepuce- rich blood and nerve supply- primary erongenous organ e. Urethral meatus i. Skene’s glands- lubricate vaginal opening f. Vaginal vestibule-enclosed by labia minora i. contains vaginal opening or introitus ii. Hymen-thin layer of tissue that surrounds introitus iii. Bartholin’s glands-secrete alkaline mucus that enhance viability and motility of sperm g. Perineal body-fibromuscular tissue between vagina and anus i. Perineum- superficial area 2. Internal Reproductive Organs a. Vagina-muscular and membranous tube that connects the external genitalia to the uterus i. Passage for sperm and fetus ii. Passage of menstrual products iii. Protection b. Uterus- hollow, muscular organ c. Fallopian Tubes-arise from each side of the uterus and turn toward ovaries i. Transport for the ovum from the ovary to the uterus (3-4 days) ii. Site for fertilization iii. Nourishing environment for ovum or zygote d. Ovaries-almond-shaped structure on each side of the pelvic cavity i. Primary source of estrogen and progesterone 3. Uterus a. 2 parts i. Corpus-uterine body 1. Fundus 2. Cornua-fallopian tubes enter 3. Isthmus-area between internal os and endometrial cavity 4. 3 layers a. Perimetrium b. Myometrium c. Endometrium b. Cervix-narrow neck of the uterus i. Chief characteristic-elasticity c. Uterine ligaments i. Broad-uterus centrally placed ii. Round-help broad ligament located near fallopian tubes iii. Ovarian-anchor ovary to the cornua of uterus iv. Uterosacral-supports uterus and cervix at the ischial spines
h. If no fertilization, CL begins to disintegrate, E&P production decreases, endometrium sheds, anterior pituitary releases FSH, LH again Chapter 4 Conception and Fetal Development
1. Cellular Division a. Gametogenesis- process by which germ cells or gametes (sperm & ovum) are produced i. Oogeneis-female ii. Spermatogenesis -male b. Meiosis- a type of cell division in which diploid cells in testes and ovaries give rise to gametes (sperm and ova) c. Each has haploid number of chromosomes (23) d. Mitosis-cell division that produces diploid cells (46) e. Sex chromosome is chromosome number 23 i. XX female XY male ii. Ovum have only X chromosomes iii. Sperm may have X or Y f. Sex is determined at moment of fertilization 2. Fertilization a. Process by which a sperm fuses with an ovum to form a diploid cell, zygote b. Ovum viable for 12-24 hours after ovulation c. Sperm viable for 24-72 hours d. Fertilization occurs in ampulla (outer third) of fallopian tube e. Only one sperm (out of 200-300 million) able to penetrate ovum due to reaction of outer layer of ovum 3. Preembryotic Development a. First 14 days fertilized ovum called a zygote b. Cells rapidly multiply and differentiate c. Multiplication i. Moves through fallopian tube by weak fluid current and beating action of ciliated epithelium that lines tube ii. Tubal peristalsis occurs in response to estrogen iii. Journey to uterine cavity can take 3 or more days iv. Once zygote has divided into 16 cells it is called a morula which is divided into blastocyst and trophoblast v. Blastocyst develops into embryo; trophoblast into chorion d. Nidation- (Implantation) Endometrium prepares for implantation i. Once implantation has occurred, now called an embryo ii. Implantation occurs 3-5 days after fertilization usually in upper part of posterior uterine wall iii. Cells of trophoblast grow into thickened endometrium and form chorionic villi 4. Cellular Differentiation a. Between 10-14 days blastocyst differentiates into primary germ layers from which all tissues, organs develop b. Primary germ layer divided into endoderm, mesoderm and ectoderm c. Embryonic membranes develop and form the amnion and chorion
- Primary Germ cell layers
6. Amniotic Fluid a. Amniotic fluid forms i. acts as a cushion for the embryo ii. controls temperature iii. permits symmetrical growth iv. allows freedom of movement so fetus doesn’t attach itself to amnion v. prevents umbilical cord compression 7. Cellular Differentiation a. Yolk sac develops day 8-9 after conception. Forms RBCs in early development until embryonic liver takes over process. Incorporated in umbilical cord b. Umbilical cord develops from amnion. 3 blood vessels (2 arteries, 1 vein) are surrounded by Wharton’s jelly. Wharton’s jelly cushions vessels, prevents compression by uterus **8. Twins
- Placental Development and Functions** a. Placenta provides metabolic and nutrient exchange between embryonic and maternal circulations b. Doesn’t develop until 3rd^ week but grows until 20 weeks (becomes thicker after 20 weeks but doesn’t get any larger) c. At term placenta weighs 400-600 gm (0.8-1.3 lbs) d. Placental functions: ********** i. Fetal Respiration ii. Fetal Nutrition iii. Fetal Excretion iv. Immune factors v. Hormone production and secretion 10. Placenta a. Maternal side red, flesh like b. Fetal side is covered by amnion and is shiny c. Placenta consists of 15- cotyledons
Physical and Psychological Changes of Pregnancy
1. Uterus a. capacity grows from 10 ml to 5000ml b. Same number of cells in myometrium but they enlarge c. Braxton Hicks contractions-irregular contractions that may be felt beginning in the 4th^ month 2. Signs of pregnancy a. Subjective (Presumptive) Changes i. Symptoms woman experiences and reports but may be due to other causes b. Objective (Probable) Changes i. Perceived by examiner but may be due to other causes c. Diagnostic (Positive) Changes i. Perceived by examiner but can be due only by pregnancy 3. Presumptive signs a. Amenorrhea- absence of menses (period) b. Nausea & vomiting c. Excessive fatigue d. Urinary frequency e. Breast changes f. Quickening- mother’s perception of fetal movement usually occurs between 16-20 weeks (usually closer to 20 weeks with first pregnancy) 4. Probable signs a. Changes in pelvic organs- i. Enlargement and softening of uterus ii. Goodell’s-softening of the cervix iii. Chadwick’s-bluish iv. Hegar’s-softening of the isthmus v. McDonald’s-ease in flexing the uterus against the cervix b. Enlargement of abdomen c. Braxton-Hicks contractions d. Uterine souffle-soft blowing sound-same rate maternal pulse e. Skin pigmentation changes f. Pregnancy tests i. OTC home tests detect hCG. Usually positive 7-10 days after conception 5. Cervix a. Cervix- endocervical cells produce a thick mucous plug i. Goodell’s sign is softening of cervix due to increased vascularity ii. Chadwick’s sign is bluish discoloration due also to vascularity iii. Hegar’s sign is softening of uterine isthmus (area between cervix and body of uterus)
- Vagina - Estrogen causes increased vaginal discharge 7. Positive signs a. Fetal Heartbeat b. Fetal Movement noted by examiner c. Visualization of fetus by ultrasound 8. What might a woman experience in pregnancy a. Harder time breathing b. Urgency to pee because baby compresses bladder c. Back problems from compression of spinal cord and organs 9. Common discomforts a. Result from physiologic and anatomic changes of pregnancy b. Can be generalized by trimester 10. First trimester a. Mostly due to hormonal influences b. Usually resolve by 12-14 weeks i. Nausea & Vomiting ii. Urinary Frequency iii. Fatigue iv. Breast Tenderness v. Increased Vaginal Discharge vi. Nasal Stuffiness & Epistaxis vii. Ptyalism: excessive saliva 11. Nausea and Vomiting a. AKA “morning sickness”: usually first sign of pregnancy
b. Occurs in 70-85% pregnancies; can be toward specific foods, occur during a specific time of day or throughout the day; Usually resolves by 12-14 weeks c. Thought to be due to elevated hCG levels but changes in carbohydrate metabolism, fatigue and emotional factors may play a part d. Small, frequent meals, eat before rising out of bed, avoid rich, spicy, greasy foods, drink carbonated beverages e. CAM: Ginger, Vitamin B6 & Unisom, Peppermint tea f. Acupressure: Sea bands/Relief bands g. RX: Phenergan, Zofran, Compazine, Diclegis (Vit B6 + antihistamine doxylamine) h. Evaluate skin turgor, mucous membranes etonuria, weight loss i. Encourage 6 small meals instead of 3 large ones, carbonated beverages help, eat a carbohydrate before getting up
12. Breast tenderness a. Related to hormonal changes particularly estrogen b. Appropriately fitted bra; wider strips c. Evaluation by bra specialist d. Enlarge and become more glandular e. Areola darken, nipples become more erect f. Striae develop g. Colostrum produced/excreted in last trimester 13. Nasal Stuffiness and Epistaxis a. Estrogen may produce edema of nasal mucosa leading to stuffiness, discharge b. Vaporizers may help but many resort to OTC nasal sprays that eventually increase symptoms over time c. Tylenol Sinus, Sudafed, Zyrtec can be used in pregnancy for severe cases 14. Increased Vaginal Discharge a. Leukorrhea b. Caused by hyperplasia of vaginal mucosa and increased mucus production c. Increase acidity encourages growth of candida albicans d. Bathe daily, avoid douching (washing of the vagina), cotton underpants e. Note complaints of vaginal pruritis (itching of the vulva), odor 15. Ptyalism a. Excessive, bitter salivation b. Unknown cause c. Chew gum, suck hard candies 16. Second and Third trimesters a. Second trimester is time when woman feels the best b. Most of the following complaints occur in third trimester but may occur earlier i. Heartburn ii. Edema iii. Varicosities iv. Flatulence v. Hemorrhoids vi. Constipation vii. Backache viii. Leg cramps ix. Faintness x. Dyspnea xi. Difficulty sleeping xii. Round ligament pain xiii. Carpal tunnel syndrome 17. Cardiovascular System a. Blood volume increases i. This includes both plasma and erythrocytes ii. Erythrocytes necessary to transport O iii. Because plasma volume greater than erythrocyte volume, anemia occurs iv. Physiological anemia of pregnancy v. Increased Fe needs to make hemoglobin vi. Leukocyte production increased up to 12,000 (20-30,000 in labor) vii. Clotting factors increase slightly making pregnancy a hypercoagulable state b. Increased cardiac output c. Increased pulse rate
a. Uterus remains a pelvic organ first trimester b. Compresses on bladder c. In 3rd^ trimester presenting compresses on bladder d. Glycosuria common-warrants further testing e. Urinary frequency i. Due to pressure of growing uterus on bladder; occurs first trimester and then again in 3rd^ trimester ii. Differentiate between frequency/urgency with dysuria, hematuria iii. Encourage 8-10 glasses of water daily but avoid drinking much after nightfall; frequent voiding iv. Evaluate for suprapubic pain, CVA tenderness to R/O pyelonephritis
- Skin and hair a. Increased skin pigmentation common especially at areola, nipples, vulva, perianal areas b. Linea nigra extends from umbilicus to pubic area c. Chloasma (melasma gravidarum) is darkening of skin over cheeks, nose, forehead d. More common in dark haired women e. Striae appear on abdomen, thighs, buttocks, breasts f. Spider nevi g. Hair growth rate decreases; postpartum women may note increase shedding of hair for 1-4 months h. Striae: stretch marks i. Linea Nigra: dark vertical line that appears on stomach in pregnacny j. Chloasma: pigmentation disorder in pregnancy- dark patches on face k. acne 30. PUPPP RASH Pruitic Urticarial Papules and Plaques of Pregnancy a. The rash almost always begins in the stretch marks (striae) of the abdomen. It does not involve the belly button distinguishing it from other common rashes of pregnancy. The rash itself consists of small, red wheals (a firm elevated swelling of the skin) in the stretch marks that grow together to form larger wheals on the abdomen. Sometimes the rash can include small vesicles (a bubble of liquid within a cell). Over the next several days, the rash can spread over the thighs, bum, breasts, and arms. b. The rash is very itchy, or pruitic, hence the name! This condition is thought to be harmless to mother and baby, but can be very annoying. It can last an average of 6 weeks and resolves spontaneously 1 to 2 weeks after delivery. The most severe itching can last for more than 1 week. 31. Musculoskeletal System a. Joints of pelvis relax resulting in waddle b. Increased lumbar curve to compensate for growing uterus- results in backache c. Diastasis recti is separation of abdominal muscles due to pressure of enlarging uterus 32. Backache a. Exaggeration of lumbosacral curve due to enlarging, heavier uterus; relaxation of pelvic joints from Relaxin hormone effect on cartilage b. Avoid bending over at waist, heavy c. lifting, high heel shoes, use good d. body mechanics (bend at knees, e. wide stance when standing) f. Treat with pelvic rock exercise, back rubs, massages g. Backaches usually present as constant pain in lower back. Must distinguish from premature uterine contractions that are usually of shorter duration and come and go. h. Posture Changes 33. Round Ligament Pain a. Enlarging uterus stretches round ligaments b. May present as intense grabbing sensation in lower abdomen and inguinal area c. Heating pad, changing position d. Distinguish between UTI, fetal movement, appendicitis 34. Leg cramps a. Painful muscle spasms of gastrocnemius muscles b. Occur most frequently at night or with extension of foot c. Due to pressure of enlarged uterus on pelvic nerves or blood vessels, poor circulation, calcium-phosphorus ration imbalance d. Relieve by dorsi-extending foot toward leg, massage, warm compresses e. Potassium supplements, bananas 35. Carpal Tunnel Syndrome a. Characterized by numbness, tingling of hand near thumb b. Due to compression of median nerve in carpal tunnel of wrist from edema of hand, shoulder; ill fitted bra may also contribute c. Aggravated by repeated hand movement
d. Treat by splintering of wrist, elevate arm
36. Metabolism a. Weight gain i. Normal weight women should gain 25-35 lbs ii. Overweight women- no more than 15 lbs iii. Underweight women – up to 40 lbs iv. 10 lbs first half v. One lb per week after 20 weeks b. Water/Nutrients i. Increased water retention ii. Protein and carbohydrate needs increase iii. Fats more completely absorbed 37. Endocrine a. Thyroid-enlarges-basal metabolic rate increases 20-25% b. Pituitary c. Anterior-FSH, LH, Prolactin d. Posterior-Vasopressin, Oxytocin e. Adrenals-Cortisol f. Pancreas-Increased insulin needs 38. Psychological Changes in Pregnancy a. Pregnancy is an experience full of growth, change, enrichment, and challenge b. Fears and expectations about becoming parents c. Emotions in both mother and father 39. Developmental tasks a. Both parents must deal with major psychosocial adjustments b. Altered body image c. Reordering of social relationships d. Change in family roles e. Common psychological/ emotional responses i. Ambivalence ii. Acceptance iii. Introversion iv. Mood swings v. Changes in body image vi. Renewed interest in her own mother vii. Grief 40. Trimester changes a. First trimester: ambivalence, feeling poorly, introspective, fear of loss b. Second trimester: Quickening makes pregnancy become more real; emotionally labile, changes in body image c. Third Trimester: Physical discomfort, anxiety about L&D, Excitement 41. Psychological tasks of mother a. Ensuring safe passage through pregnancy, labor, birth b. Seeking acceptance of this child by others c. Seeking commitment and acceptance of herself as mother to infant (binding in) d. Learning to give of oneself on behalf of one’s child 42. Psychological tasks of father a. May experience initial excitement but role undefined b. May become more real once fetal movement palpated c. Couvade: unintentional development of physical symptoms of partner
e. Rupture of Membranes f. Sudden Burst of Energy g. Weight Loss h. Increased backache and sacroiliac pressure i. Diarrhea, indigestion, or nausea and vomiting
50. False Labor vs True labor a. Contractions i. False: inconsistent in frequency, duration and intensity 1. Exercise does not alter ctxs ii. True: consistent increase in frequency, duration, and intensity
- Exercise increases ctxs b. Discomfort i. False: felt in abdomen and groin. May be more annoying that painful ii. True: begins in lower back, sweeps around to lower abdomen. Early labor feels like cramps c. Cervix i. False: no change in effacement or dilation ii. True: progressive effacement and dilation **Maternal Nutrition CH 12
- Maternal weight gain** a. Underweight women: 28-40 lbs b. Normal weight women: 25-35 lbs c. Overweight women: 15-25 lbs d. Obese women: 15 lbs e. Approximately 300 calorie daily increase 2. Weight Gain Distribution a. Fetus, placenta, amniotic fluid: 11 lbs b. Uterus: 2 lbs c. Increased blood volume: 4 lbs d. Breast tissue: 3 lbs e. Maternal stores: 5-10 lbs anticipating extra stores for breast feeding after pregnancy) f. Ideal weight gain i. 1 st^ trimester: 3.5-5 lbs ii. 2 nd^ trimester: 12-15 lbs iii. 3 rd^ trimester: 12-15 lbs 3. WIC Program a. Women, Infants & Children i. Federally funded program providing nutritional support to pregnant and nursing women and children under age 5 b. Being underweight could get you on the WIC program: like a debt card that you can use in the grocery store- only certain foods that fit healthy women c. Counseling with nutritionist, breastfeeding support and education, exercise classes- yoga 4. Nutritional Requirements a. Balanced diet of carbohydrates, protein and fat b. Vitamin/mineral supplementation i. Fe (iron) supplementation for Hgb < 10 grams 1. Consume with OJ, not milk, caffeine: best opportunity for absorption ii. Vitamin A not included as most consume adequate levels: can be toxic to the fetus iii. Folic acid deficiency associated with Neural Tube Defects; reproductive aged women should take 400 mcg daily c. Fluids, especially water (8-10 glasses daily) 5. Nutritional History a. Subjective information i. Journals, daily diaries, questionnaires ii. 24 hour recall b. Objective information i. Weights: taken every appointment to ensure healthy weight gain ii. Lab values 6. Foods to Avoid a. Deep sea fish d/t concerns re mercury b. Swordfish, shark, mackerel
c. No more than 12 oz weekly of fish, shellfish d. Avoid albacore tuna e. Mercury exposure can cause CNS abnormalities, cognition, (language, attention, memory) f. Salmonella may be found in raw eggs, cake batter, homemade ice cream g. Listeria bacteria found in unpasteurized dairy, meat, poultry i. Avoid hot dogs, deli meats, luncheon meats ii. Avoid soft cheeses (feta, brie, camembert)
7. Cravings a. Very real in pregnancy but some don’t have them b. Pickles, ice, chips, or ice-cream are common examples c. Encourage healthy snacks instead of cravings d. Not twice the calories but pay attention to what you are consuming 8. PICA: eating non-food sources a. Craving and consumption of nonnutritive substances b. Soil, clay, starch, laundry detergent, ice c. Must ask patient; very few will freely admit d. Suspicion of pica if Fe(iron) deficient e. Thorough history – ask about pica directly i. Education surrounding this **Assessment of Fetal Well-being
- Why do we assess the fetus?** a. To evaluate the fetus: fetal monitoring system is “babies call light system” b. To confirm fetal well being c. To identify fetal compromise 2. Indications for fetal assessment a. Decreased fetal movements b. Elevated MSAFP, Quad Screen, cfDNA c. History of preterm labor, genetic problems d. Maternal medical history e. Multiple gestations f. Post-term gestations g. PROM h. IUGR fetus i. Vaginal bleeding j. Maternal Age: Advanced Maternal Age (AMA) k. History of stillbirth
- Fetal heart rate (FHR) a. Assessed during each prenatal visit from 12 wks (Doppler) or 20 wks with Fetoscope b. 120 –160 bpm is normal (110-160 at term) c. Failure to hear FHR may result from i. User error ii. Obesity iii. Polyhydramios: lot of fluid- need internal monitoring iv. IUGR / SGA fetus v. Fetal Death d. If patient is heavier or has polyhydramios then we need to use an internal fetal heart monitor 4. Fetal Doppler a. At 8 weeks you can hear fetal heart rate 5. Ultrasonography a. Indications: helps to determine fetal growth, we can also confirm gestational age and EDD if woman doesn’t know last menstrual cycle or has irregular one b. First Trimester i. Gestational Age/viability ii. Congenital anomalies iii. Vaginal bleeding iv. Fetal growth c. Second Trimester i. Congenital anomalies ii. Guidance for procedures iii. Placental location/grading
b.
11. Non-reactive test a. Try repositioning mother, apply oxygen- 10L non-rebreather mask to get oxygen to baby, bolus to increase volume and perfusion b. 12. Contraction stress Test (CST) a. Assessment of FHR in response to contractions b. Indications: to see if baby can handle contractions i. IUGR DM Postdates Nonreactive NST BPP c. Contraindications: i. Placenta previa, placental abruption, previous c-section with classical incision, PROM, incompetent cx, hx PTL, hx of multiple gestation d. Procedure: i. Criteria: 3 contractions lasting 40sec in 10 minutes ii. Contractions from nipple stimulation or oxytocin iii. Contraction decreases oxygenation to fetus but fetus should tolerate it if it has good placental reserve e. Interpretation: i. Negative: No late decelerations “Good” ii. Positive: Late decelerations “Bad” iii. Equivocal: suspicious or difficult to interpret f. Management i. Negative: Repeat in 7 days ii. Positive: >32 wks C-Section iii. Equivocal: Repeat in 24 hrs 13. Positive CST (BAD) a. 3 contractions lasting 40 seconds in 10 minutes, late decelerations seen
b.
14. Biophysical Profile a. Indications: i. Non-reactive NST: this is the follow up test ii. Suspected oglio or polyhydramnios iii. Suspected fetal hypoxia iv. PROM v. Maternal infection b. Look for these 5 things: i. Reactive Fetal Heart Rate (pos NST):NST via ultrasound ii. Fetal Breathing Movements iii. Gross Body Movements: large body movements iv. Fetal Tone: how contracted the baby is v. Amniotic Fluid Volume: pocket of fluid on monitor c. Fetus receives either 0 or 2 points for each category. Top score 10/ 15. Amniocentesis a. Indications: i. 16-18 wks - chromosomal, biochemical measurement ii. 30-35 wks- lung maturity, infection iii. 24-36 wks- Fetal hemolytic disease management iv. Elevated fetal fibronectin levels b. Procedure: i. Empty bladder, lateral tilt, fetal evaluation done prior to and after start of procedure ii. Use ultrasound to identify fetal parts, pocket of amniotic fluid iii. Administer Rhogam if Rh negative mother c. Complications: i. Fetal, umbilical, placenta injury, hemorrhage, infection, preterm labor ii. Complication rate <1% 16. Fetal Lung Maturity a. Lecithin/Sphingomyelin Ratio (L/S Ratio) b. Surfactant required for sustained respirations: helps to keep lungs open and avoid sticking together c. L & S are two components of Surfactant d. Ratio of 2:1 or 2.0 indicates RDS unlikely e. Phosphatidylglycerol (PG) f. Appears when fetal lung maturity obtained around 35 weeks g. Reported as present or absent 17. Other diagnostic tests a. Nuchal Translucency i. US done between 11-14 weeks gestation. NT may be done in correlation with serial blood tests ii. Could show for trisomy 21 b. Fetoscopy i. Direct observation and obtainment of sample of skin or blood ii. Fetal hemoglobinopathies, immunodeficient disease, Chromosomal defects c. Doppler Flow Studies i. studies maternal fetal blood flow ii. measures velocity RBCs travel through uterine and fetal vessels iii. Assists with management of IUGR, poor placental perfusion, at risk pregnancies d. Percutaneous Umbilical Blood Sampling i. Cordocentesis UV blood sample and transfusion ii. Kleihauer-Betke test determines if blood from fetal or maternal source e. MRI
