The FETAL AND MATERNAL HEALTH

Teratogenicity Prenatal Care Click to edit Master subtitle style Maternal Adaptation to Pregnancy Psychological/Emotional Adaptation to Pregnancy

2/15/13

Teratogens

Common things that can harm fetal development.

Click to edit Master subtitle style

2/15/13

TERATOGENS

substances that are toxic to some part of a developing embryo or fetus Word root: terato- = monster -gen = to make
CATEGORY
A B

DESCRIPTION
Well controlled studies in women fail to demonstrate a risk to the fetus Animal studies do not demonstrate a risk, no studies in women Animal studies uncovered some risk, but no adequate studies in women Animal studies indicates adverse risk to the fetus, and no controlled studies in women. Studies in women and animal are not available Human experiences shows association of drugs with birth defects, but the potential benefits of a drug may be accepted

D 2/15/13

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
2/15/13

Nicotine and Cocaine

Both nicotine and cocaine are known to be addictive. Developing fetuses become addicted too. Both drugs constrict blood vessels. This decreases oxygen delivery to the fetus.

Results of Nicotine and Cocaine 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.

2/15/13

Nicotine and other drugs can also cause Neural tube defects

A neural tube defect is a problem with the formation of the brain and/or spinal cord. The most common neural tube defects are spina bifida and myelomeningocoel.

www.obgyn.net/us/us.asp?page=gallery/ galle

Alcohol

Alcohol is an addictive and LEGAL drug. Beer, wine and liquor all affect the fetus the same. Just as alcohol damages adult brains, it also damages fetal brains.

Bothwww.mofas.org/guidelines/ character.htm brains are from 6 week old new borns.

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

2/15/13

Prescription drugs can also be harmful.

Even prescriptions that you took before pregnancy should be carefully considered. Anti-epileptic drugs, acne treatments, sedatives and antibiotics can damage developing fetuses. Streptomycin anti TB & or Quinine (anti malaria)

Anticonvulsiv es

Common prescriptions for controlling epilepsy can have bad effects. Dilantin, Valproic acid and Trimethadione can all cause defects. Always discuss medications with your prenatal physician.

Diethylstilbestrol (DES)

This drug was given to treat menstrual cramps and prevent miscarriages. It was found to have toxic effects on the sex organs of the babies. It affects both male and female

Thalidomide

This used to be given to prevent morning sickness. Many children whose moms took thalidomide were horribly deformed. This drug is no longer given to pregnant women.

Thalidomide affected the development of arms and legs.

2/15/13

Goals of Prenatal Care:

What is 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 her family

Definition of Terms: Gravida Nulligravida Primigravida Multigravida Para.Parity refers to the number of pregnancies that has reached the period of viability (possibility of survival outside the uterus, after 24 weeks gestation, at least 20 cm length, or at least 600g)regardless of the number of fetuses and whether it is dead

2/15/13

Local Setting: Components of Prenatal Care at the BHS and RHU

1.

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

Risk factors that needs close monitoring and 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 Physical Examination per visit Treatment of Diseases TT Immunization Supplementation Health Education Laboratory Examination Oral Dental

2/15/13

2. 3. 4. 5. 6. 7. 8.

Local Setting: Components of Prenatal Care at the BHS and RHU

9. Referral when necessary 10. Home Delivery Only normal cases are qualified for home delivery 11. Postnatal services

Components of Prenatal Clinic Visit

First Clinic Visit is a time to obtain baseline data through interview, laboratory test and complete physical examination. Activities on initial clinic visit consist primarily of:

History Taking Complete PE Lab test Fetal Assessment Health Teaching

Subsequent Clinic Visits A. Maternal Assessment

Blood Pressure Weight Nutrition

2/15/13

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 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

C. Health Teaching

2/15/13

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?

G3P2
A woman who has had two abortions at 3 months and is again pregnant. What is the GP?

G3PO
A patient who is pregnant for the second time, but miscarried her first pregnancy would be ;
2/15/13

Obstetrical History Taking

T.P.A.L.
T the or after P the weeks A the L the Example: number of full term infant born at 37 weeks number of preterm infant born before 37 number of induced/spontaneous abortion number of living children

A woman who has 2 living children born as preterm twins in her first pregnancy would be designated as. GTPAL? G1 P 0-1-0-2
A 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 commonly referred to as miscarriage), and one (the twin to the one delivered pre-term) is living

G2P 0-1-1-1

2/15/13

NCLEX Question:
Mrs. Donna, pregnant for 16 weeks age of gestation (AOG), visits the health care facility for her prenatal check-up with her only son, Mark. During assessment the client told the nurse that 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 at about 20 weeks AOG. Based on the data obtained, Mrs. 2/15/13 Donnas GTPAL score is:

Leopold's Maneuver
Inobstetrics,Leopold's Maneuversare a common and systematic way named to determine after the the position of afetusinside the woman'suterus; they are gynecologistChristian Gerhard Leopold. They are also used to estimate term fetal weight. Themaneuversconsist of four distinct actions, each helping to determine the position of the fetus. The maneuvers are important because they help determine 2/15/13 the position and presentation of thefetus, which in conjunction with

Leopold's Maneuver

Leopold's Maneuvers performed by onobesewomenand women who havepolyhydramnios. Thepalpationcan sometimes are difficult to perform

beuncomfortablefor the woman if care is not taken to ensure she is relaxed and adequately positioned.

To aid in this, thehealth care providershould first ensure that

2/15/13

Leopold's Maneuver
First maneuver: Fundal Grip

2/15/13

While facing the woman,palpatethe woman's upper abdomen with both hands. A professional can often determine the size, consistency, shape, and mobility of the form that is felt. Thefetalhead is hard, firm, round, and moves independently of thetrunkwhile thebuttocksfeel softer, aresymmetric, and the shoulders and limbs have

Leopold's Maneuver
Second maneuver: Umbilical Grip

2/15/13

After the upperabdomenhas been palpated and the form that is found is identified, the individual performing the maneuver attempts to determine the location of the fetal back. Still facing the woman, the health care provider palpates the abdomen with gentle but also deep pressure using the palm of thehands. First the right hand remains steady on one side of the abdomen while the left hand explores the right side of the woman'suterus. This is then repeated using the opposite side and hands. The fetal back will feel firm and smooth while fetalextremities(arms, legs, etc.) should feel like small irregularities

Leopold's Maneuver
Third maneuver: Pawlick's Grip

2/15/13

In the third maneuver the health care provider attempts to determine what fetal part is lying above the inlet, or lower abdomen.The individual performing the maneuver first grasps the lower portion of the abdomen just above thepubic symphysiswith thethumbandfingersof the right hand. This maneuver should yield the opposite information and validate the findings of the first maneuver. If the woman enterslabor, this is the part which will most likely come first in avaginal birth. If it is the head and is not actively engaged in thebirthing process, it may be gently pushed back and forth. The Pawlick's Grip, although

Leopold's Maneuver
Fourth maneuver: Pelvic Grip

2/15/13

The last maneuver requires that the health care provider face the woman's feet, as he or she will attempt to locate the fetus'brow. The fingers of both hands are moved gently down the sides of the uterustoward thepubis. The side where there is resistance to the descent of the fingers toward the pubis is greatest is where thebrowis located. If the head of the fetus is well-flexed, it should be on the opposite side from the fetalback. If the fetal head is extended though, theocciputis

Maternal Adaptation to Pregnancy

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 clotting factors Endocrine Changes Placenta starts producing estrogen, progesterone, HCG, HPL Elevated estrogen and progesterone level suppresses the LH, 2/15/13 FSH, Oxytocin

Pathogenic Anemia iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women. Assessment reveals:

Pallor, constipation Slowed capillary refill Concave fingernails (late sign of progressive anemia) due to chronic physio-hypoxia

2/15/13

Nursing Care:
Nutritional instruction kangkong, liver due

give IM, Z tract- if improperly administered, hematoma. 2/15/13

Parenteral Iron ( Imferon) severe anemia,

to ferridin content, green leafy vegetablealugbati,saluyot, malunggay, horseradish, ampalaya

Alert:

Iron from red meats is better absorbed than Iron is better absorbed when taken with foods Higher

form other sources

high in Vitamin C such as orange juice

2/15/13

iron intake is recommended since circulating blood volume is increased and

Edema

lower extremities due venous return is constricted due to large belly, elevate legs above hip level.
use support stockings, avoid wearing knee high socks use elastic bandage lower to upper

Varicosities pressure of uterus

Vulbar

gravid uterus to relieve- position side lying with pillow under hips or modified knee chest position
2/15/13

varicosities-

painful,

pressure

on

Thrombophlebitis
o o o o

presence of thrombus at inflamed blood vessel

pregnant mom hyper-fibrinogenemia increase fibrinogen increase clotting factor thrombus formation candidate

outstanding sign (+) Homan's sign pain on cuff during dorsiflexion

o

Management

Bed rest o Never massage o Assess + Homan 2/15/13 thrombus

sign

once

only

might

dislodge

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 2/15/13 Increased in size ,larger nipples and more pigmented

Maternal Adaptation to Pregnancy

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 (18003600gm) HPL, estrogen, progesterone and insulin produced by the placenta during pregnancy oppose the action of insulin during pregnancy. Fats are more completely absorbed during pregnancy, plasma 2/15/13 lipid levels increase during the second half of pregnancy

Maternal Adaptation to Pregnancy

Maternal Adaptation to Pregnancy

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

2/15/13

Gastrointestinal Changes v Nausea and Vomiting on the first trimester v Pika/Pica craving for nonfood stuff or unusual food stuffs is common in some cultures v Hemorrhoids are common v Effects of PROGESTERONE
v v v
v

Maternal Adaptation to Pregnancy

Constipation Pyrosis/Heartburn Generalized itching Ptylaism Epulis

Effects of ESTROGEN
v v

Skeletal Changes v Softening of the joints, ligaments v Low backache v Lordosis v Leg Cramps 2/15/13

Leg Cramps
prolonged standing, fatigue, Ca & phosphorous imbalance(#1 cause while pregnant) chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus

Management:
Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 34 servings/day. Cheese, yogurt, head of fish, Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab.

Vitamin D for increased Ca absorption Dorsiflexion

2/15/13

Psychological/Emotional Adaptations to Pregnancy

Acceptance of Pregnancy Second Trimester Accepting the Baby Third Trimester Preparing for Parenthood
First Trimester
First Trimester Acceptance of the reality of pregnancy is the first psychological task that a woman is about to become a mother faces. Aside from the signs and symptoms of pregnancy is experienced, the doctors conformation often helps the woman to accept the fact the she is pregnant. At this stage the unborn is incorporated as part of the woman's body image or as part of herself. Second Trimester Quickening by 20 weeks gestation can be very significant in helping the woman realize that the fetus inside her womb is not just a part of her body but a real and separate individual of care. She begin to fantasize about the sex and appearance. The woman becomes introspective during this stage because she is preoccupied wit the fantasies about her unborn child.

2/15/13

Psychological/Emotional Adaptations to Pregnancy

Acceptance of Pregnancy Second Trimester Accepting the Baby Third Trimester Preparing for Parenthood
First Trimester Third Trimester The woman begins to plan about the birth of the baby. She select babys layette, choose name for her baby, makes plan on how the baby will be fed, where the baby will sleep at home. Emotional Reactions Experienced by a Newly Pregnant Woman Ambivalence Fear and Anxiety Introversion or Narcissism Uncertainty

2/15/13

TYPES OF PELVIS

2/15/13

2/15/13

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. 2/15/13

Internal Measurement of Pelvis

2/15/13

Internal Measurement of Pelvis

Diagonal Conjugate is the distance between the sacral prominence and the anterior surface of the SP. This is the most useful measurement for estimation of the pelvic size. If this measurement is more than 12.5 cm the pelvic inlet is adequate. True Conjugate or conjugate vera, is the measurement between the AP surface of the sacral prominence and the posterior surface of the inferior margin of the SP. 10.5 to 11 cm. Ischial Tuberosity diameter is the distance between the ischial tuberosities or the transverse diameter of the outlet. A Williams 2/15/13 or Thomas pelvimeter is

Diagonal Conjugate

2/15/13

2/15/13

2/15/13

Nutritional Needs During

Pregnancy
Pounds 7 1.5 1.76 2.1 .9 3.2 3.2 7.3 26.96

Components of Maternal Weight Gain

Fetal Part Fetus Placenta Amniotic Fluid Uterus Breast Blood Extra vascular Fluid Maternal Stores Total 2/15/13 Kilograms 3.4 .6 .8 .97 .4 1.45 1.48 3.3 12.5

Nutritional Needs During

Pregnancy

Nutritional Risk Factors

Pregnant Adolescent Successive Pregnancies Maternal Weight Low Income Pregnancy Complications and Existing Medical Condition Alcohol Consumption and Cigarette Smoking Bizarre Food Patterns Women on Vegetarian Diets

2/15/13

Nutritional Needs During

Pregnancy
Abnormal weight gain: 1. Weight gain is less than 2 lb a month on the 2nd and 3rd trimester 2. Weight gain of more than 2 lb a week is a sign of hypertension of pregnancy 3. Further evaluation is needed if weight gain is persistently slow or does not equal to 10 lb by mid pregnancy

2/15/13

Nutritional Needs During

Pregnancy
What are the NUTRITIONAL REQUIREMENTS:

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 meet energy 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 has been 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 2/15/13 30% fat

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 induces hypertension (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 adolescents must supply protein for their own growth as well as protein t meet the pregnancy requirement

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 ensure ingestion of sufficient quantities of all amino acids

2/15/13

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 2/15/13 Vitamin D sources: fortified milk, margarine, egg yolk, butter, liver, seafood

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 to meet 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 2/15/13 iron from food sources is more readily absorbed when served with foods high in vitamin C

Zinc and Folic Acid, Folacin, 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 placenta q 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 dietary deficiency q 4 servings of grains/day Increases should reflect: q liver, kidney, lean beef, veal 2/15/13 leafy vegetables, broccoli, legumes. q dark green