fetal and maternal health

7/29/2019 Fetal and Maternal Health

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The FETAL AND MATERNAL

HEALTHTeratogenicityPrenatal CareMaternal Adaptation to PregnancyPsychological/Emotional Adaptation to

Pregnancy


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TeratogensCommon things that can harm

fetal development.


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TERATOGENS substances that are toxic to some part of a developing

embryo or fetus

Word root: terato- = monster

-gen = to make

CATEGORY DESCRIPTION

A Well controlled studies in women fail to demonstrate a risk tothe fetus

B Animal studies do not demonstrate a risk, no studies in women

Animal studies uncovered some risk, but no adequate studies inwomen

C Animal studies indicates adverse risk to the fetus, and nocontrolled studies in women. Studies in women and animal arenot available

D Human experiences shows association of drugs with birthdefects, but the potential benefits of a drug may be accepted


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TERATOGENS

Recereational Drugs Narcotics Cocaine Crack

Teratogenicity of Alcohol

Congenital Deformities Metal Retardation FAS

Teratogenicity of Cigarette Environmental Teratogenes Radiation Hyperthermia/Hypothermia Teratogenicity of Maternal Stress


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Nicotine and Cocaine

Both nicotine andcocaine are known to beaddictive.

Developing fetusesbecome addicted too.

Both drugs constrictblood vessels.

This decreases oxygendelivery to the fetus.


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Results of Nicotine andCocaine Use

Low birth weight babies,because they didnt get

enough oxygen to grow. Newborns going through

withdrawal from drugs. Most cannot adjust their own

body temperatures.


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can also cause Neuraltube defects

A neural tubedefect is a problemwith the formationof the brain and/orspinal cord.

The most commonneural tube defectsare spina bifida andmyelomeningocoel.

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Alcohol

Alcohol is anaddictive and

LEGAL drug. Beer, wine and

liquor all affect thefetus the same.

Just as alcoholdamages adultbrains, it alsodamages fetal

brains.

Both brains are from 6 week oldnew borns.

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Some Potentially/Positively Teratogenic Drugs

Accutane Congenital anomalies Androgens Masculinization of the female fetus Antiepileptics Cleft lip and palate, Congenital heart

anomalies

Antineoplatics Anxiolytics Congenital malformation Iodide 131 Destroy the thyroid of the fetus Oral anticoagulant Bleeding Phenothiazines Retinopathy Vaccine Vitamin c


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Prescription drugs can also beharmful.

Even prescriptions thatyou took beforepregnancy should be

carefully considered. Anti-epileptic drugs, acne

treatments, sedatives

and antibiotics candamage developingfetuses.

Streptomycin anti TB &

or Quinine (anti malaria)


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Anticonvulsives

Common prescriptions

for controlling

epilepsy can have bad

effects.

Dilantin, Valproicacid and

Trimethadione can all

cause defects.

Always discuss

medications with your

prenatal physician.


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Diethylstilbestrol (DES)

This drug wasgiven to treat

menstrual crampsand preventmiscarriages.

It was found to

have toxic effectson the sex organsof the babies.

It affects both

male and female


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Thalidomide

This used to begiven to prevent

morning sickness. Many children

whose moms tookthalidomide were

horribly deformed. This drug is no

longer given topregnant women.

Th lid id ff t d th


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Thalidomide affected thedevelopment of arms andlegs.


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CARE?Goals of Prenatal Care: To ensure a healthy and uncomplicated pregnancy and

the delivery of a healthy infant To identify and treat high risk condition

To individualize patient care To assist the patient for her preparation for labor,

delivery and puerperium To screen and identify risk factors or disease that may

affect the mother or the infants health and life

To reinforce healthy habits to the woman and herfamily

Definition of Terms:

GravidaNulligravida

Primigravida

Multigravida

Para.Parity refers to the number of pregnancies that has reachedthe period of viability (possibility of survival outside the uterus,

after 24 weeks gestation, at least 20 cm length, or at least600g)regardless of the number of fetuses and whether it is dead


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Local Setting: Components of PrenatalCare at the BHS and RHU

1. History Taking (HBMR) is used when rendering prenatal care inpregnancy, childbirth and postpartum period identifying risk factors,danger signs, health education and referrals.

Risk factors that needs close monitoringand referrals:

Below 18 years old and above 35 years old

Below 4 feet or 145 cm

5th or more pregnancy

Previous CS

Previous postpartum hemorrhage

TB

Heart Diseases

Diabetes

Bronchial Asthma

Goiter

Three consecutive abortion

2. Physical Examination per visit

3. Treatment of Diseases

4. TT Immunization

5. Supplementation

6. Health Education

7. Laboratory Examination8. Oral Dental

l i f l


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Local Setting: Components of PrenatalCare at the BHS and RHU

9. Referral when necessary

10. Home Delivery Only normal cases are qualified for homedelivery

11. Postnatal services

Components of Prenatal Clinic Visit

First Clinic Visit is a time to obtain baseline data throughinterview, laboratory test and complete physicalexamination. Activities on initial clinic visit consistprimarily of:

History Taking

Complete PE

Lab test

Fetal Assessment Health Teaching

Subsequent Clinic Visits

A. Maternal Assessment Blood Pressure

Weight Nutrition


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Components of Prenatal Clinic Visit

B. Fetal assessment FHR

Quickening Fundal Ht.

Specific assessment

Abdominal palpation

Late in Pregnancy vaginal examination, pelvic measurement,dilatation and station and cervical effacement

C. Health Teaching Normal s/sx of pregnancy

Minor discomforts, prevention management

Danger signs of pregnancy

Nutrition and diet

Rest, exercise

Avoid drugs, alcohol, cigarettes and too much caffeine Clothing

Sexual relations

Employment

Travel

Preparation for babys birth, labor, delivery and puerperium


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Obstetrical History Taking

G.P and T.P.A.L.(Gravida.Parity.Term.Preterm.Abortion.Living)

Example:

A woman who has had two previous pregnancies, has

delivered two term children, and is again pregnant.What is the GP?

G3P2A woman who has had two abortions at 3 months and

is again pregnant. What is the GP?

G3POA patient who is pregnant for the second time, butmiscarried her first pregnancy would be ;


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Obstetrical History Taking

T.P.A.L.T the number of full term infant born at 37 weeksor after

P the number of preterm infant born before 37

weeksA the number of induced/spontaneous abortion

L the number of living children

Example:

A woman who has 2 living children born as preterm twins in herfirst pregnancy would be designated as. GTPAL?

G1 P 0-1-0-2A patient was pregnant twice, did not carry any to full-term, had one pre-term(pre-mature), had one abortion (or spontaneous abortion which is commonlyreferred to as miscarriage), and one (the twin to the one delivered pre-term) is

livingG2P 0-1-1-1


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NCLEX Question:

Mrs. Donna, pregnant for 16 weeksage of gestation (AOG), visits the healthcare facility for her prenatal check-upwith her only son, Mark. During

assessment the client told the nursethat previously she got pregnant twice.The first was with her only child, Mark,who was delivered at 35 weeks AOG and

the other pregnancy was terminated atabout 20 weeks AOG.

Based on the data obtained, Mrs.Donnas GTPAL score is:


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Leopold's Maneuver

In obstetrics, Leopold'sManeuvers are a common and systematic

way to determine the position of

a fetus inside the woman's uterus; they are

named after the gynecologist Christian

Gerhard Leopold. They are also used to

estimate term fetal weight.

The maneuvers consist of four

distinct actions, each helping to determine

the position of the fetus. The maneuvers

are important because they help determine

the position and presentation of the fetus,which in con unction with


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Leopold's Maneuver

Leopold's Maneuvers performed

by are difficult to perform

on obese women and women who

have polyhydramnios.

The palpation can sometimes

be uncomfortable for the woman

if care is not taken to ensure she

is relaxed and adequately

positioned.

To aid in this, the health care

provider should first ensure that


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Leopold's ManeuverFirst maneuver: Fundal Grip

While facing thewoman, palpate thewoman's upper abdomenwith both hands. Aprofessional can oftendetermine the size,consistency, shape, andmobility of the form that isfelt.

The fetal head is hard, firm,round, and movesindependently ofthe trunk whilethe buttocks feel softer,

are symmetric, and theshoulders and limbs have


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Leopold's ManeuverSecond maneuver: UmbilicalGrip After the upper abdomen has been

palpated and the form that is foundis identified, the individualperforming the maneuver attemptsto determine the location of the fetal

back. Still facing the woman, thehealth care provider palpates theabdomen with gentle but also deeppressure using the palm ofthe hands.

First the right hand remains steadyon one side of the abdomen whilethe left hand explores the right sideof the woman's uterus. This is thenrepeated using the opposite side andhands.

The fetal back will feel firm andsmooth while

fetal extremities (arms, legs, etc.)should feel like small irregularities


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Leopold's ManeuverThird maneuver: Pawlick'sGrip In the third maneuver the health

care provider attempts to determinewhat fetal part is lying above theinlet, or lower abdomen.Theindividual performing the maneuver

first grasps the lower portion of theabdomen just above the pubicsymphysis withthe thumb and fingers of the righthand.

This maneuver should yield theopposite information and validatethe findings of the first maneuver. Ifthe woman enters labor, this is thepart which will most likely come firstin a vaginal birth.

If it is the head and is not activelyengaged in the birthing process, it

may be gently pushed back andforth. The Pawlick's Grip, although


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Leopold's ManeuverFourth maneuver: PelvicGrip

The last maneuver requires thatthe health care provider face thewoman's feet, as he or she will

attempt to locate thefetus' brow. The fingers of bothhands are moved gently downthe sides of the uterus towardthe pubis.

The side where there is

resistance to the descent of thefingers toward the pubis isgreatest is where the brow islocated. If the head of the fetusis well-flexed, it should be on theopposite side from the

fetal back. If the fetal head isextended thou h the occi ut is

Maternal Adaptation to


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Maternal Adaptation toPregnancy

Cardiovascular Changes The heart is displaced upwards There may be splitting of the heart sound, with common systolic

murmurs Cardiac Volume increases by 40 to 50% causing slight cardiac

hyperthrophy and increase in CO Physiologic Anemia Total circulating blood cells increases Leukocyes count is elevated during labor

Fibrinogen levels increased by 50% along with other clottingfactors

Endocrine Changes Placenta starts producing estrogen, progesterone, HCG, HPL

Elevated estrogen and progesterone level suppresses the LH,FSH Ox tocin


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Pathogenic Anemia iron deficiency anemia isthe most common hematological disorder. Itaffects toughly 20% of pregnant women.

Assessment reveals: Pallor, constipation Slowed capillary refill Concave fingernails (late sign of progressive

anemia) due to chronic physio-hypoxia


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Nursing Care:

Nutritional instruction kangkong, liver dueto ferridin content, green leafy vegetable-

alugbati,saluyot, malunggay, horseradish,

ampalaya Parenteral Iron ( Imferon) severe anemia,

give IM, Z tract- if improperly administered,

hematoma.


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Alert:

Iron from red meats is better absorbed than

form other sources

Iron is better absorbed when taken with foods

high in Vitamin C such as orange juice

Higher iron intake is recommended since

circulating blood volume is increased and


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Edema lower extremities due venous return is

constricted due to large belly, elevate legs abovehip level.

Varicosities pressure of uterus use support stockings, avoid wearing knee high socks use elastic bandage lower to upper

Vulbar varicosities- painful, pressure ongravid uterus to relieve- position side lying with pillow

under hips or modified knee chest position


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Thrombophlebitis presence of thrombus at inflamed blood vessel

o pregnant mom hyper-fibrinogenemiao increase fibrinogeno increase clotting factoro thrombus formation candidate

outstanding sign

(+) Homan's sign pain on cuff during

dorsiflexion

Managemento Bed resto Never massageo Assess + Homan sign once only might dislodgethrombus



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Reproductive System Enlargement and thickening of the uterus most manifested in

the fundus Starting at 12 weeks gestation , the fundus can already be

palpated as it rises out of the pelvic cavity. Being muscular, the uterus undergoes irregular contractions

starting on the first trimester. Hegars Sign Color of the cervix change in color from pinkish to purplish Leukorrhea ---- mucus plug ---- SHOW Ovulation ceases throughout pregnancy Increased vascularity, hyperemia, and softening of the perineum

and vulva Vaginal secretion increases, decrease PH 3.5 to 6 Breast becomes tender and tingle in the early weeks of

pregnancy Increased in size ,larger nipples and more pigmented



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Integumentary System Striae Gravidarum reddish, slightly depressed streaks in the

abdominal wall, breast and the thighs Linea Nigra line of dark pigment extending from the umbilicus

down the midline of the symphysis pubis. Chloasma are brownish patches of pigment on the face

Metabolic Changes Weight Gain is average 11 to 13 kgs (24-28 lbs) Fetus (3400gm), Placenta (450 gm), AF (900 gm), Breast Tissue

(1400gm), Blood Volume (1800gm), Maternal Store (1800-3600gm)

HPL, estrogen, progesterone and insulin produced by theplacenta during pregnancy oppose the action of insulin duringpregnancy.

Fats are more completely absorbed during pregnancy, plasmalipid levels increase during the second half of pregnancy



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Respiratory Changes Hyperventilation occurs Enlarging uterus elevates the diaphragm Thoracic cage expands by means of flaring of the ribs

Nasal Stuffiness

Urinary Tract Changes Ureters becomes dilated and oblongated GFR increase

Glocusuria Protein in the urine should be reported



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Gastrointestinal Changesv Nausea and Vomiting on the first trimesterv Pika/Pica craving for nonfood stuff or unusual food stuffs is common in

some culturesv Hemorrhoids are commonv Effects ofPROGESTERONE

v Constipationv Pyrosis/Heartburn

v Generalized itching

v Effects ofESTROGENv Ptylaism

v Epulis

Skeletal Changesv Softening of the joints, ligamentsv Low backachev Lordosis

v Leg Cramps


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Leg Cramps

prolonged standing, fatigue, Ca & phosphorous imbalance(#1 cause while pregnant)

chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerveplexus

Management:

Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis, sardines withbones, brocolli, seafood-tahong (mussels), lobster, crab.

Vitamin D for increased Ca absorption

Dorsiflexion

h l i l/ i l d i


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Psychological/Emotional Adaptations to

Pregnancy

First Trimester Acceptance of PregnancySecond TrimesterAccepting the Baby

Third Trimester Preparing for Parenthood

First Trimester

Acceptance of the reality of pregnancy is the first psychological task that a woman isabout to become a mother faces. Aside from the signs and symptoms of pregnancyis experienced, the doctors conformation often helps the woman to accept the factthe she is pregnant. At this stage the unborn is incorporated as part of the woman'sbody image or as part of herself.

Second Trimester

Quickening by 20 weeks gestation can be very significant in helping the womanrealize that the fetus inside her womb is not just a part of her body but a real andseparate individual of care. She begin to fantasize about the sex and appearance.

The woman becomes introspective during this stage because she is preoccupied witthe fantasies about her unborn child.

h l i l/ i l d i


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Psychological/Emotional Adaptations to

Pregnancy

First Trimester Acceptance of PregnancySecond TrimesterAccepting the Baby

Third Trimester Preparing for Parenthood

Third Trimester

The woman begins to plan about the birth of the baby. She select babyslayette, choose name for her baby, makes plan on how the baby will befed, where the baby will sleep at home.

Emotional Reactions Experienced by a Newly Pregnant Woman Ambivalence Fear and Anxiety Introversion or Narcissism Uncertainty


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TYPES OF PELVIS


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TYPES OF PELVIS

Gynecoid Pelvis

This is the normal female pelvis. The inlet of this type of

pelvis is well rounded forward and backward, and the pubic

arch is wide. This type of pelvis ideal for childbirth.

Anthropoid Pelvis

This has a long,oval brim in which the antero-posterior

diameter is longer than the transverse.This does not

accommodate a fetal head. an ape like

Platypelloid Pelvis

This flat pelvis has a kidney-shaped brim in which the

anteposterior diameter is reduced and the transverse

increased. flattened one the inlet is oval smoothly curved.

A fetal head would not be able to rotate to matched the curve.Android pelvis

male pelvis the pubic arch of this type pelvis forms an

acute angle making the lower diameter of the pelvis extremely

narrow.

Internal Measurement of


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Internal Measurement ofPelvis

Internal Measurement of


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Internal Measurement ofPelvis

Diagonal Conjugate is thedistance between the sacralprominence and the anteriorsurface of the SP. This is themost useful measurement forestimation of the pelvic size. Ifthis measurement is more than12.5 cm the pelvic inlet isadequate.

True Conjugate or conjugatevera, is the measurementbetween the AP surface of the

sacral prominence and theposterior surface of the inferiormargin of the SP. 10.5 to 11 cm.

Ischial Tuberositydiameter isthe distance between the ischialtuberosities or the transverse

diameter of the outlet. A Williamsor Thomas pelvimeter is


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Diagonal Conjugate


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N t iti l N d D i


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Nutritional Needs DuringPregnancy

Components of Maternal Weight Gain

Fetal Part Pounds Kilograms

Fetus 7 3.4

Placenta 1.5 .6

Amniotic Fluid 1.76 .8

Uterus 2.1 .97

Breast .9 .4

Blood 3.2 1.45

Extra vascularFluid 3.2 1.48

Maternal Stores 7.3 3.3

Total 26.96 12.5

Nutritional Needs During


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Nutritional Risk Factors Pregnant Adolescent Successive Pregnancies

Maternal Weight Low Income Pregnancy Complications and Existing

Medical Condition

Alcohol Consumption and CigaretteSmoking Bizarre Food Patterns Women on Vegetarian Diets



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Abnormal weight gain:

1. Weight gain is less than 2 lb a month on

the 2nd and 3rd trimester2. Weight gain of more than 2 lb a week is asign of hypertension of pregnancy

3. Further evaluation is needed if weight gainis persistently slow or does not equal to 10 lbby mid pregnancy



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What are the NUTRITIONALREQUIREMENTS:

Essential to supply energy for increased metabolic rate

Utilization of nutrients protein sparing so it can be used for growth of fetus

Development of structures required for pregnancy including placenta, amniotic fluid, and tissue growth.

300 calories/day above the pre-pregnancy daily requirement to maintain ideal body weight and meetenergy requirement to activity level

Begin increase in second trimester

Use weight gain pattern as an indication of adequacy of calorie intake.

Failure to meet caloric requirements can lead to ketosis as fat and protein are used for energy; ketosis hasbeen associated with fetal damage.

Caloric increase should reflect :

Foods of high nutrient value such as protein, complex carbohydrates (whole grains, vegetables, fruits)

Variety of foods representing foods sources for the nutrients requiring during pregnancy

No more than 30% fat

Protein


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Protein

Essential for: Fetal tissue growth

Maternal tissue growth including uterus and breasts

Development of essential pregnancy structures

Formation of red blood cells and plasma proteins

* Inadequate protein intake has been associated with onset of pregnancy induceshypertension (PIH)

60 mg/day or an increase of 10% above daily requirements for age group

Adolescents have a higher protein requirement than mature women since adolescentsmust supply protein for their own growth as well as protein t meet the pregnancyrequirement

Protein increase should reflect:

Lean meat, poultry, fish Eggs, cheese, milk

Dried beans, lentils, nuts

Whole grains

* vegetarians must take note of the amino acid content of CHON foods consumed to ensureingestion of sufficient quantities of all amino acids

Calcium Phosphorous


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Calcium-Phosphorous

Essential for:

Growth and development of fetal skeleton and tooth buds Maintenance of mineralization of maternal bones and teeth Current research is : Demonstrating an association between adequate calcium intake and the

prevention of pregnancy induce hypertension

Calcium increases of : 1200 mg/day representing an increase of 50% above prepregnancy daily

requirement. 1600 mg/day is recommended for the adolescent. 10 mcg/day of vitamin D is

required since it enhances absorption of both calcium and phosphorous

Calcium increases should reflect:

dairy products : milk, yogurt, ice cream, cheese, egg yolk whole grains, tofu green leafy vegetables canned salmon & sardines w/ bones

Ca fortified foods such as orange juice Vitamin D sources: fortified milk, margarine, egg yolk, butter, liver, seafood

Iron


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Iron

Essential for:

Expansion of blood volume and red blood cells formation

Establishment of fetal iron stores for first few months of life

30 mg/day representing a doubling of the pregnant daily requirement

Begin supplementation at 30- mg/day in second trimester, since diet alone is unable tomeet pregnancy requirement

60 120 mg/day along with copper and zinc supplementation for women who have low

hemoglobin values prior to pregnancy or who have iron deficiency anemia. 70 mg/day of vitamin C which enhances iron absorption

inadequate iron intake results in maternal effects anemia depletion of iron stores,decreased energy and appetite, cardiac stress especially labor and birth

fetal effects decreased availability of oxygen thereby affecting fetal growth

* iron deficiency anemia is the most common nutritional disorder of pregnancy.

Iron increases should reflect:

liver, red meat, fish, poultry, eggs

enriched, whole grain cereals and breads

dark green leafy vegetables, legumes

nuts, dried fruits

vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, broccoli or cabbage,

potatoes iron from food sources is more readil absorbed when served with foods hi h in vitamin C


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, ,Folate

Zinc is Essential for:

* the formation of enzymes

* maybe important in the prevention of congenital malformation of the fetus.

15mcg/day representing an increase of 3 mg/day over pre-pregnant daily requirements.

Zinc increases should reflect

q liver, meats

q shell fish

q eggs, milk, cheese

q whole grains, legumes, nuts

Folate/Folacin/Folate is Essential for:

q formation of red blood cells and prevention of anemia

q DNA synthesis and cell formation; may play a role in the prevention of neutral tube

defects (spina bifida), abortion, abruption placentaq 400 mcg/day representing an increase of more then 2 times the daily prepregnant

requirement. 300mcg/day supplement for women with low folate levels or dietarydeficiency

q 4 servings of grains/day

Increases should reflect:

q liver kidney lean beef veal

fetal and maternal health

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