Maternity Nursing

Family Centered Maternity Care - empowering/educating the whole family, encouraging early & frequent prenatal care to prevent IntraUterine Growth Restriction (IUGR) = small baby = SGA (small for gestational age)

            - WIC (women infants & children) provides education regarding nutrition

            - Self-care can involve complementary & alternative medicines, aromatherapy, touch therapy...

            - Drugs that have caused fetal defects in the past: Thalidamide - shortened limbs, no limbs, hands growing straight from shoulder... was originally given to combat morning sickness; DES (diethylsybestril) an antiabortion medication that caused reproductive cancers in the child w/2nd & 3^rd generations of children having cancers

Nutritional Supplements - a woman should have good nutritional habits BEFORE getting pregnant

- Folic Acid: to prevent Neural tube defects, epileptics need extra folic acid

- Brewer’s yeast: B12

- Wheat Germ: B vitamins

- Garlic: for circulatory health

- Fish oil: omega 3 fatty acids

Mind & Body Therapies - meditation, yoga, massage, hydrotherapy, aromatherapy, regular exercise may all be helpful, especially if the woman already engages in these activities

Midwives - Birth attendants, provide education, engage parents in a more collaborative role; a Doula may provide home care, is often an RN, supports the family prenatally during labor & w/postnatal visits

Legal & Ethical Care - ethical duty to maintain a professional attitude & demeanor; Patient has a legal right to give informed (this means that the patient understands!!) consent, has a right to privacy & has the right to confidentiality (except where mandated by law); nurses are responsible for providing competent & up to date care by participating in continuing education; Legally a pregnant underage teen is an emancipated minor but the male partner is not emancipated unless they marry

Ethical Considerations - Unborn children qualify for health benefits, Abortion is always a political issue (we cannot make it part of our practice to tell people what WE think they ought to do!), Fetal research is also an ongoing political issue, Reproductive assistance is not an idea that all people will be receptive to

Infant Mortality & Morbidity - Mortality = # of infant deaths per 1000 births, is highest for adolescents & women in their 40's, in the US is 6.9 in every 1000; Maternal Mortality = has decreased steadily in the last 40 years; Morbidity = refers to the # of people who have a specific disease of condition

Culturally Diverse Society - Marriage: you cannot assume that a mother & father are married; Blood: many families are grandparent headed, some families have multiple generations under one roof; Adoption: always a difficult decision; Single parent families, stepparent families, & gay & lesbian couples are more & more common

Amish Customs - often have home births, families are supportive during labor, families will often bring food to the hospital, the general thinking is that hospitals are only for sick people

Asian Population - believe there are hot/cold behaviors, Ying = cold/dark/wet, Yang = light/hot/dry, showering is cold, won’t always shower immediately after birth, want to avoid cold behaviors, after birth may only drink room temperature drinks, the grandmother or significant other may take care of the baby initially

Jewish Ritual & birth - Circumcision is done on the 8^th day during a Bris ceremony by a Mohel, using the Mogen clamp method, this is often when the baby is named & blessed by the rabbi, the baby is often given a drop or two of wine

Latino culture - often believe that the baby is a blessing no matter what, may be dressed in clothes family brings; Curandera is a folk healer; La Parteras are midwives

Salpingectomy - removal of fallopian tube

Oopherectomy - ovary removal

Tubal Ligation - fallopian tubes severed, usually not reversible

Ovaries are dormant during pregnancy except during 1^st 12 weeks they release estrogen & progesterone; progesterone slows peristalsis & can = constipation for mom does = nutrients for the baby; HCG is stimulated by progesterone release, HCG is secreted by the embryo until the placenta is fully developed; Relaxin is secreted by the uterus, it relaxes joints to allow expansion for birth

Pelvic Anatomy - viewed under ultrasound, Conjugata Vera, Obstetric Conjugate, & Diagonal Conjugate (is really important), ultrasound biparietal measure of baby’s head to see if it will fit through pelvic opening, Relaxin opens the symphasis pubis; Pelvic outlet is estimated w/fist

Uterus - weighs 2-2.5 pounds, capacity increases from 10mL to 5L, Estrogen causes hypertrophy (enlargement) of cells of the uterus, specifically myometrial cells, there is limited hyperplasia;  Autolysis allows the uterus to return to non-pregnant state after pregnancy; uterus changes from anteverted to retroverted w/woman’s activity; Fibroids are common in older women, may be very painful & may lose a lot of blood

Umbilical cord - is 20 cm long by birth, usually stems from center of placenta, cord placement occurs at the same time as major vessels, abnormal placenta can equal abnormal baby; should have 2 arteries & 1 vein at birth

Placenta - weighs 1.5-2 pounds, only 3 things don’t pass through the placenta: insulin (it’s too large), heparin, Iron Dextran

Vagina - increased vascularization, increased secretion but should not be malodorous, thick & white discharge is more acidic, pH 3.5-6.0, increased risk of yeast infections, general relaxation of tissue; green & frothy discharge may mean trichomonis, gonorhea may lead to smelly white discharge, chlamydia may lead to white odor free discharge, syphillis is often undetected, Herpes causes lesions, GBS is normal vaginal flora, can cause fetal infections (meningitis), TORCH diseases: CMV, toxoplasmosis (from cat litter), Herpes, syphillis, Rubella, can cause severe anomalies & mom may not know she has it; After birth vaginal wall has less rugae

Cervix - softens (Goodell’s sign) as if was originally hard as a nose & now is soft as an earlobe; changes to blue/purple color (Chadwick’s sign) which is more important in a primipra, not as visible in a multipria; mucous plug forms at cervical opening, cervix increases discharge, becomes increasingly vascularized; most of these changes occur by the 2^nd missed period

Breasts - increase in size d/t the influence of: progesterone (affects the lactation process) & estrogen (increases the size of breasts) (estrogen & progesterone help keep a woman pregnant), Tenderness is noticeable early, striae are purple & red stretch marks, colostrum may be made as early as the 12^th week; the areola becomes darker, Montgomery glands (little glands on edge of areola) are more prominent

Skin & Hair changes - Linea Nigra (black line) umbilicus to symphasis pubis about 12^th week & baby may also have it d/t influence of maternal hormones, Chloasma “mask of pregnancy” racoon eyes, Abdominal striae d/t skin stretching, vascular spider nevi broken blood vessels in thighs/calves, hair growth decreases & may lose hair, sebaceous & sweat gland production increases & may get acne

Respiratory System - Pulmonary function changes: consumption increases, diaphragm elevates, some dyspnea or SOB, actual disease may be aggravated (but there is still an attempt to limit medication usage); Nasal stuffiness & congestion & sometimes nosebleeds d/t estrogen increasing vascularization around the nose

Cardiovascular System - Slight lateral displacement, slight murmur may be normal, blood volume increases, physiologic anemia of pregnancy d/t increase plasma & RBC ‘s stay the same (mom’s treated early w/prenatal vitamins w/extra iron) this anemia happens 40-50% of the time; Cardiac output increases by 30-50% & a mom w/heart disease might be on a diuretic; Pulse rate increases 10-15bpm & tends to drop immediately after birth, BP shows slight decrease; moms w/heart problems often have to go to high risk clinic before & during pregnancy more frequently than other moms; Vena Caval Syndrome: feeling of fainting when pregnant woman lies flat, VERY common

GI System - general discomforts of pregnancy: nausea/vomiting d/t HCG (give crackers before getting OOB, eat small meals before bed so that moms don’t wake up hungry, low fluid intake before bed, women often experience projectile vomiting w/limited nausea (may not be much warning before vomit, may feel fine immediately afterward); Ptyalism (excessive salivation), Pryosis (heartburn - eat small frequent meals low in fat, low in spices), Constipation & hemorrhoids (increase fiber, fruits, & veggies), Gallbladder smooth muscle relaxation (d/t progesterone), Puritus; If a women loses weight d/t N/V it’s a problem but otherwise N/V is not a problem, mom should gain 2-4 pounds in the 1^st trimester; Hyperemesisgraviderum: excessive vomiting that is a problem & must be addressed

Urinary Tract - capacity is reduced d/t uterus pushing on bladder but mom must drink because too little H2O can lead to preeclampsia; slight dilation of right kidney & ureter which increases risk for infection, GFR & RPF increase, glycosuria not unusual, creatinine clearance shows good function; UTI = back pain, fever, burning urination, progesterone slows everything down & increases the risk of UTI

Musculoskeletal - dental problems are not associated w/pregnancy (that’s an old wive’s tale), relaxation of joints d/t Relaxin gives women a pregnant waddle (remind mom to keep head up straight to avoid balance problems & falls r/t postural changes), Diastasis Recti - separation of abdominal muscles, still looks pregnant after delivery, sometimes needs to be surgically repaired; Muscle cramps in legs/calves d/t baby stealing mom’s Ca+, Braxton-Hicks when it’s abdominal cramps

Endocrine Changes - Thyroid: BMR increases 20-25% & people w/thyroid problems to begin w/may not get pregnant until the problem is controlled; Parathyroid hormone increases d/t fetal calcium needs, Pituitary posterior lobe maintains the LH (oxytocin & vasopressin suppress uterine activity to prevent preterm labor); Anterior lobe of pituitary secretes prolactin during pregnancy

Pancreas: increased demands can lead to gestational diabetes: found at 23-28 wk evaluation, test to make sure mom can produce enough insulin because if she can’t she gets a special diet w/insulin; Insulin resistance to ensure glucose to the fetus (the goal is to get sugar to the baby), the placenta produces hPL & prolactin & elevated cortisol from the adrenals; If mom has high blood sugar, so does the baby & the baby gets FAT

Pregnancy Hormones - hCG - human chorionic gonadotropin: from the Corpus Luteum , by 12 weeks from the placenta; Estrogen: responsible for new cell development & prepares breasts for lactation; Progesterone: maintains pregnancy & slows down every body system; Relaxin from the Corpus Luteum & decidua of the uterus; Prostaglandins help initiate labor, may use baby aspirin to help decrease/regulate prostaglandins, preterm labor can be stopped w/Indomethacin (a tocolytic), Prostaglandin gel softens the cervix & gets it ready once oxytocin comes & then labor begins (prostaglandins ripen cervix); Placental lactogenic hormone from pituitary lets lactation happen; Pregnant women are often labile d/t hormone changes

Fetal Development - hCG peaks early, by 120 days hCG levels have fallen off & progesterone & estrogen are on the rise, at full term estrogen is primary hormone; by term the placenta is not functioning at full capacity anymore

Signs of Pregnancy -  Presumptive signs (subjective signs): amenorrhea, N/V, urinary frequency, breast changes, quickening, fatigue; Objective signs (Probable pregnancy): Pelvic organ changes, abdominal enlargement, Braxton Hicks contractions, uterine souffle (blood through major arteries in the uterus), pigmentation changes, ballottement, pregnancy tests, palpation of fetal outline, Hegar’s sign (softening of lower uterine segement); Positive Signs: fetal heartbeat (about 120 -160), fetal movements, visualization of the fetus

Prenatal Care - early intervention is KEY!!!!! EDC, EDD, Nagele’s Rule (LMP subtract 3 months & add 7 days) is often +/- 2 weeks; Gravida is the number of pregnancies (not deliveries!), Nullipara never pregnant, Primipara first pregnancy, Multipara multiple pregnancies

Para - TPAL tells us mom’s history; T Term Pregnancies (37 wks +), P Prematures (36-20 wks), A Abortions (before 20 wks), L Living Children; this information is not changed in the chart immediately after the baby is born, it is updated at her next visit, twins count as 1 pregnancy because the uterus is only pregnant once, if a baby dies in utero at 24 wks it’s a premie

Prenatal Assessment - Personal history (chronic disease history), Physical exam: Laboratory tests: blood & urine, glucose screening at 20-24 wks, AFP at 16-18 wks (increase means neural tube defects, decrease can means Down Syndrome), Pelvic exam; Ultrasound: fundal height & structure to check for IUGR; Diagnostic tests (screening tests, not perfect): AFP, MSAFP, triple check: AFP, hCG, urine estriol) for neural tube defects trisomy 28 or 18; quadruple screen: AFP, hCG, urine estriol, & inhibin A; Amniocentesis: done after a positive AFP, takes 10 days - 2 weeks to get results, tests for genetic abnormalities (early) & near term for respiratory evaluation (LS ratio)

Danger signs of pregnancy - persistant vomiting, vaginal bleeding (can be abortion, placenta previa, abruption...) swelling of upper body (preeclampsia, lower body swelling is normal), severe headache &/or vision changes (can be BP problems), Abdominal pain (usually liver involvement d/t preeclampsia advancement), chills & fever (CMV), sudden gush of fluid from vagina (premature rupture of membranes?)

Subsequent Visits - weight gain: should be slow & steady; fundal height: should increase 1cm every visit & at 12 wks be at symphysis pubis, by 40 wks should be almost at diaphragm; FHT’s (at 10-12 wks can monitor fetal heart rate); Urine (sugar & protein screens), Blood Pressure; Fetal Movement Test: how much movement w/in an hour, often after meals, average over a couple of days; Smoking will cause a small placenta

Psychological Development of Pregnancy - Maturational Crisis of the mother: ambivalence (excitement, fear), Acceptance (most women accept before their male partners), Introversion (egocentric, very self-centered), mood swings (decreased HbG during pregnancy may lead to increased risk of post-partum depression), body image (some wear maternity clothes from day 1 & some people refuse to wear maternity clothes), the death of someone significant or a recent major trauma can cause delayed acceptance

Couvade - Father taking on mom’s symptoms, usually dads experience lots of fantasy/daydreams/worries; Couvade is a culturally sanctioned construction, in more intense ritualistic form the father may take over the phenomena of the pregnancy & the pains during delivery; attenuated forms in Westernized culture