Nancy Pares, RN, MSN Metro Community College    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.  Context ◦ Who is involved, what is the setting ◦ What other information is needed ◦ What personal beliefs of the nurse may impact the situation  Clarification of the issues ◦ What are the ethical issues ◦ Who should decide the issue  Identification of alternatives and potential outcomes  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  Resolution ◦ What is the best action in this situation ◦ What strategy should be used to carry out this action  Evaluation ◦ What were the outcomes ◦ Should this same action be used in the future for similar dilemmas      Professional Nurse Certified Registered Nurse Nurse Practitioner Clinical Nurse Specialist Certified Nurse Midwife        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  Standards of care: ◦ Minimum criteria for competent, proficient, delivery of nursing care    Institutional policies Ethical implications Scope of practice ◦ Defined by state Nurse Practice Act  laws     There was a duty to provide care. The duty was breached. Injury occurred. The breach of duty caused the injury (proximate cause).  Divergence between rights of mother and rights of fetus: ◦ Mother may refuse fetal intervention. ◦ Fetal intervention may be forced on mother.  Fetal research: ◦ Therapeutic vs. non-therapeutic  Intrauterine fetal surgery: ◦ ◦ ◦ ◦ Therapy for anomalies incompatible with life Health of the mother and fetus is at risk Surrogate, frozen embryo, Female circumcision  Abortion  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      Infertility Human stem cells Cord blood Maternal refusal for c/del Maternal refusal for fetal surgery    Womens’ health standards by Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) State Boards Individual facilities policy        A holistic interpersonal approach Adequate documentation Communication Updated and realistic policies and procedures Appropriate delegation Question deviations from the standar Follow chain of command  Transforms research findings into clinical practice: ◦ Efficiency improvement ◦ Better outcomes ◦ Quality improvement   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)  Mitosis: ◦ Exact copies of original cell  Meiosis: ◦ Production of new organism  Deletion ◦ Loss of chromosome material  Translocation ◦ Misplacement  Nondisjunction ◦ Chromosomes don’t separate correctly  Karotype ◦ Chromosomal make up of an individual Mosaicism two or more genetically different cell populations in an individual      Interphase Prophase Metaphase Anaphase Telophase  First division: ◦ Chromosomes replicate, pair, and exchange information. ◦ Chromosome pairs separate, and cell divides.  Second division: ◦ Chromatids separate and move to opposite poles. ◦ Cells divide, forming four daughter cells.      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.   Production of sperm First meiotic division: ◦ Primary spermatocyte replicates and divides.  Second meiotic division: ◦ Secondary spermatocytes replicate and divide.  Produce four spermatids.     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  Capacitation: ◦ Removal of plasma membrane and glycoprotein coat ◦ Loss of seminal plasma proteins  Acrosomal reaction: ◦ Release of enzymes ◦ Allows entry through corona radiata   Zone pellucida blocks additional sperm from entering Secondary oocyte completes second meiotic division ◦ Forms nucleus of ovum    Nuclei of ovum and sperm unite Membranes disappear Chromosomes pair up   Fraternal: two ova and two sperm Identical: single fertilized ovum - Originate at different stages     Cleavage Blastomeres form morula Blastocyst: - develops into embryonic disc and amnion Trophoblast: - develops into chorion    Occurs 7 to 10 days after fertilization Blastocyst burrows into endometrium Endometrium is now called decidua  Primary germ layers: ◦ Ectoderm ◦ Mesoderm ◦ Endoderm   Metabolic and nutrient exchange Maternal portion: ◦ Decidua  Fetal portion: ◦ Chorionic villi  Fetal surface covered by amnion    Chorionic villi form spaces in decidua basalis Spaces fill with maternal blood. Chorionic villi differentiate: ◦ Syncytium: outer layer ◦ Cytotrophoblast: inner layer  Anchoring villi form septa   Body stalk fuses with embryonic portion of the placenta Provides circulatory pathway from chorionic villi to embryo: ◦ One vein  Delivers oxygenated blood to fetus: ◦ Two arteries      Nutrition Excretion Fetal respiration Production of fetal nutrients Production of hormones       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      Trachea is developed Liver produces blood cells Trunk is straighter Digits develop Tail begins to recede       Eyelids are closed Tooth buds appear Fetal heart tones can be heard Genitals are well-differentiated Urine is produced Spontaneous movement occurs       Lanugo begins to develop Blood vessels are clearly developed Active movements are present Fetus makes sucking motions Swallows amniotic fluid Produces meconium     Subcutaneous brown fat appears Quickening is felt by mother Nipples appear over mammary glands Fetal heartbeat is heard by fetoscope    Eyes are structurally complete Vernix caseosa covers skin Alveoli are beginning to form   Testes begin to descend Lungs are structurally mature    Rhythmic breathing movements Ability to partially control temperature Bones are fully developed but soft and flexible   Increase in subcutaneous fat Lanugo begins to disappear     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     Quality of sperm or ovum Genetic code Adequacy of intrauterine environment Teratogens  Maternal effects: ◦ ◦ ◦ ◦  Malnutrition Bone-marrow suppression Increased incidence of infections Liver disease Neonatal effects: ◦ Fetal alcohol spectrum disorders (FASD)      Seizures and hallucinations Pulmonary edema Respiratory failure Cardiac problems Spontaneous first trimester abortion, abruptio placentae, intrauterine growth restriction (IUGR), preterm birth, and stillbirth    Decreased birth weight and head circumference Feeding difficulties Neonatal effects from breast milk: ◦ Extreme irritability ◦ Vomiting and diarrhea ◦ Dilated pupils and apnea  Maternal effects: ◦ ◦ ◦ ◦ ◦ ◦ Poor nutrition and iron-deficiency anemia Preeclampsia-eclampsia Breech position Abnormal placental implantation Abruptio placentae Preterm labor  Maternal effects: ◦ Premature rupture of the membranes (PROM) ◦ Meconium staining ◦ Higher incidence of STIs and HIV  Fetal effects: ◦ IUGR ◦ Withdrawal symptoms after birth    Marijuana: difficult to evaluate, no known teratogenic effects PCP - maternal overdose or a psychotic response MDMA (Ecstasy) - long-term impaired memory and learning    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.     Favorable cervical mucus Clear passage between cervix and tubes Patent tubes with normal motility Ovulation and release of ova    No obstruction between ovary and tubes Endometrial preparation Adequate reproductive hormones     Normal semen analysis Unobstructed genital tract Normal genital tract secretions Ejaculated spermatozoa deposited at the cervix      Ovulation Cervix Uterine structures Tubal patency Semen analysis  Ovulatory: ◦ Pharmacologic treatment ◦ Donor oocytes  Cervical: ◦ THI, IVF, GIFT  Uterine/Tubal: ◦ IVF, GIFT ◦ Donor oocytes or gestational carrier  Sperm: ◦ THI, IVF, GIFT ◦ Micromanipulation       Marriage may be stressed Relationship affected by intrusiveness Guilt Frustration Anger Shame       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    Counselor Educator Advocate   Maternal age 35 or over Family history: ◦ Known or suspected Mendelian genetic disorder ◦ Birth defects and/or mental retardation  Previous pregnancies: ◦ Previous child with chromosomal anomaly ◦ Previous child with metabolic disorder ◦ Two or more first trimester spontaneous abortions  Parental genetics: ◦ Couples with a balanced translocation ◦ Couples who are carriers for a metabolic disorder   Abnormal MSAFP Women with teratogenic risk      Multigenerational 50% chance of passing on the gene Males and females equally affected Varying degrees of presentation Diseases ◦ Achondroplasia ◦ Marfans ◦ Neurofibromotosis  Achondroplasia ◦ Most common dwarfism, lifespan and IQ WNL  Marfans ◦ Connective tissue disorder, triad of ocular, skeletal and CV alterations  Neurofibromotosis (Von Recklinhausen) ◦ Soft tumor development of peripheral nerves       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     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      Genetic ultrasound Genetic amniocentesis Chorionic villus sampling Percutaneous umbilical blood sampling MSAFP     Educate about tests Provide support Refer for counseling Resource during and after counseling  Identify the maternal fetal effects of TORCH (toxoplasmosis, other, rubella, cytomegalovirus, herpes) infections and the corresponding nursing interventions.       Toxoplasmosis Rubella Cytomegalovirus Herpes simplex virus Group B streptococcus Human B-19 parvovirus      Retinochoroiditis Convulsions Coma Microcephaly Hydrocephalus    Congenital cataracts Sensorineural deafness Congenital heart defects       Neurologic complications Anemia Hyperbilirubinemia Thrombocytopenia Hepatosplenomegaly SGA    Preterm labor Intrauterine growth restriction Neonatal infection      Respiratory distress or pneumonia Apnea Shock Meningitis Long-term neurologic complications    Spontaneous abortion Fetal hydrops Stillbirth  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 .     Endocrine disorder of carbohydrate metabolism Results from inadequate production or utilization of insulin Cellular and extracellular dehydration Breakdown of fats and proteins for energy   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  Early pregnancy: ◦ Increased insulin production and tissue sensitivity  Second half of pregnancy: ◦ Increased peripheral resistance to insulin      Hydramnios Preeclampsia-eclampsia Ketoacidosis Dystocia Increased susceptibility to infections       Perinatal mortality Congenital anomalies Macrosomia IUGR RDS Polycythemia   Hyperbilirubinemia Hypocalcemia  Assess risk at first visit: ◦ Low risk - screen at 24 to 28 weeks ◦ High risk - screen as early as feasible       Age over 40 Family history of diabetes in a first-degree relative Prior macrosomic, malformed, or stillborn infant Obesity Hypertension Glucosuria  One-hour glucose tolerance test: ◦ Level greater than 130-140 mg/dl requires further testing  3-hour glucose tolerance test: ◦ GDM diagnosed if 2 levels are exceeded    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      AFP Fetal activity monitoring NST Biophysical profile Ultrasound       Assessment of glucose Nutrition counseling Education about the disease process and management Education about glucose monitoring and insulin administration Assessment of the fetus Support  Maternal complications: ◦ Susceptible to infection ◦ May tire easily ◦ Increased chance of preeclampsia and postpartal hemorrhage ◦ Tolerates poorly even minimal blood loss during birth  Fetal complications: ◦ ◦ ◦ ◦ Low birth weight Prematurity Stillbirth Neonatal death  Prevention and treatment: ◦ Prevention - at least 27 mg of iron daily ◦ Treatment - 60-120 mg of iron daily  Maternal complications: ◦ Nausea, vomiting, and anorexia  Fetal complications: ◦ Neural tube defects   Prevention - 4 mg folic acid daily Treatment - 1 mg folic acid daily plus iron supplements  Maternal complications: ◦ ◦ ◦ ◦ Vaso-occlusive crisis Infections Congestive heart failure Renal failure   Fetal complications include fetal death, prematurity, and IUGR. Treatment: ◦ Folic acid ◦ Prompt treatment of infections ◦ Prompt treatment of vaso-occlusive crisis  Treatment: ◦ Folic acid ◦ Transfusion ◦ Chelation      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     Intrapartal or postpartal hemorrhage Postpartal infection Poor wound healing Infections of the genitourinary tract   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)  Counsel about implications of diagnosis on pregnancy: ◦ Antiretroviral therapy ◦ Fetal testing ◦ Cesarean birth      Congenital heart disease Marfan syndrome Peripartum cardiomyopathy Eisenmenger syndrome Mitral valve prolapse       Rheumatoid arthritis Epilepsy Hepatitis B Hyperthyroidism Hypothyroidism Maternal phenylketonuria    Multiple sclerosis Systemic lupus erythematosus Tuberculosis       Tubal damage Previous pelvic or tubal surgery Endometriosis Previous ectopic pregnancy Presence of an IUD High levels of progesterone      Congenital anomalies of the tube Use of ovulation-inducing drugs Primary infertility Smoking Advanced maternal age   Methotrexate Surgery      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       Vaginal bleeding Anemia Passing of hydropic vesicles Uterine enlargement greater than expected for gestational age Absence of fetal heart sounds Elevated hCG    Low levels of MSAFP Hyperemesis gravidarum Preeclampsia    D&C Possible hysterectomy Careful follow-up     Monitor vital signs Monitor vaginal bleeding Assess abdominal pain Assess the woman’s emotional state and coping ability     Control vomiting Correct dehydration Restore electrolyte balance Maintain adequate nutrition       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     Preeclampsia-eclampsia Chronic hypertension Chronic hypertension with superimposed preeclampsia Gestational hypertension       Maternal vasospasm Decreased perfusion to virtually all organs Decrease in plasma volume Activation of the coagulation cascade Alterations in glomerular capillary endothelium Edema     Increased viscosity of the blood Hyperreflexia Headache Subcapsular hematoma of the liver     Small for gestational age Fetal hypoxia Death related to abruption Prematurity       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       Bed rest High-protein, moderate-sodium diet Treatment with magnesium sulfate Corticosteroids Fluid and electrolyte replacement Antihypertensive therapy       Scotomata Blurred vision Epigastric pain Vomiting Persistent or severe headache Neurologic hyperactivity   Pulmonary edema Cyanosis       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   To prevent injury, raise padded side rails Administer magnesium sulfate  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      Rh – mother, Rh + fetus Maternal IgG antibodies produced Hemolysis of fetal red blood cells Rapid production of erythroblasts Hyperbilirubinemia      After After After After After birth of an Rh+ infant spontaneous or induced abortion ectopic pregnancy invasive procedures during pregnancy maternal trauma     Mom is type O Infant is type A or B Maternal serum antibodies are present in serum Hemolysis of fetal red blood cells       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       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       Psychological distress Loss of pregnancy Preterm labor Low-birth-weight infants Fetal death Increased risk of STIs