MOTHER

SUBSTANCE ABUSE DURING PREGNANCY

I. DEFINTION/DESCRIPTION
 The four general categories of substances abused by pregnant women are central nervous
system depressants, including alcohol, sedatives, anxiolytics, and hypnotics; stimulants,
including cocaine and amphetamines; opiates; and hallucinogens/psychotomimetics,
including lysergic acid diethylamide (LSD) and phencyclidine (PCP). With the exception of
caffeine and nicotine, these substances are associated with both abuse and dependence
disorders.
 The effects of substance abuse during pregnancy may be classified into three categories:
effects on the mother, effects on the course of pregnancy and delivery, and effects on the
fetus, newborn, and developing child.

II. INCIDENCE

Substance abuse during pregnancy is more prevalent than commonly realized, with up to 25% of
gravidas using illicit drugs. In fact, substance abuse is more common among women of reproductive
age than among the general population. The average pregnant woman will take four or five drugs
during her pregnancy, with 82% of pregnant women taking prescribed substances and 65% using
nonprescription substances, including illicit drugs.  

III. RISK FACTORS

 Substance abuse during pregnancy can lead to multiple health and social problems for both
the mother and child, including miscarriage, stillbirth, low birth weight, prematurity, physical
malformations and neurological damage (WHO, ND).
IV. MANIFESTATIONS
 Blotchy skin coloring
 Diarrhea
 Excessive or high-pitched crying
 Abnormal sucking reflex
 Fever
 Hyperactive reflexes
 Increased muscle tone
 Irritability
 Poor feeding
 Rapid breathing
 Seizures
 Sleep problems
 Slow weight gain
 Stuffy nose and sneezing
 Sweating
 Trembling
 Vomiting

Effects of using some drugs could be long-term and possibly fatal to the baby:95
 Birth defects
 Low birth weight
 Premature birth
 Small head circumference
 Sudden infant death syndrome (sids)

V. MANAGEMENT
 Lab exam/diagnostic procedure
 After comparing the sensitivity and specificity of maternal interview, maternal hair analysis,
and meconium analysis in detecting perinatal exposure to opiates, cocaine, and marijuana, a
study concluded that both meconium and hair analyses yielded the highest sensitivities for
detecting perinatal use of opiates and cocaine. Maternal hair analysis, although a good
screening test for detecting maternal drug use during the previous 3 months with drug
metabolites persisting for up to 3 months in the infants hair after birth, is falsely positive in
those women exposed passively to second-hand smoke from crack cocaine and marijuana.
Although theoretically useful, hair analysis is unavailable to most clinicians on a routine
basis.
 They concluded that meconium analysis, which is easily performed, gives a picture of the
drug use pattern during the latter half of pregnancy and may be the ideal screening test for
maternal drug use. Because meconium can be attained only at delivery, it is not useful for
antepartum screening. In clinical practice, urine toxicology assays are more frequently
ordered. Although these assays can detect maternal drug use within the past 48 to 72 hours,
they may miss the infrequent users and cannot quantify the frequency or amount of drug
used. Some physicians rely more heavily on the substance abuse history, often combining it
with the urine drug screen.
 Biologic screening for substance abuse should be performed only with informed consent
from the mother and for the purpose of treating the substance abuse disorder once
identified.

 Treatment
 Abstinence should be the ultimate goal of the management and treatment of substance
abuse during pregnancy. Researchers have found that participating in prenatal care alone
can improve the outcome of the substance abuse pregnancy and that ceasing substance use
during the pregnancy can further decrease perinatal morbidity.
 According to Schrager and coworkers, a residential treatment program combined with
consistent outpatient follow-up is the best way to prevent or decrease maternal substance
use. Other treatment options include formal counseling programs, self-help groups,
women’s shelters, and halfway houses. Involuntary treatment should be considered when
the substance abuser refuses to enter a treatment program and when her behavior creates
significant problems for herself and the fetus.
 CARE AFTER DETOXIFICATION
o The pregnant drug abuser should be seen frequently, ideally at 2-week intervals until
32 to 34 weeks, then weekly, with urine drug screens obtained at each visit.
Rehabilitation services include educational sessions, group and individual
counseling, and 12-step groups. Reed suggests that services individually address the
women’s unique treatment needs, reduce barriers to intervention and recovery,
 express goals compatible with the patient’s lifestyle, and consider the special issues
associated with pregnancy.

 Nursing Responsibilities
 Takes a detailed medical and social history. It is of highly importance to ask questions in the
right manner so they do not seem threatening to the woman and build a trusting
relationship with the woman.
 Work closely with the social worker and be thoroughly informed on the subjects, through
continuous professional development.

References

 Wilson (2020). Substance Abuse in Pregnancy. Retrieved from:

https://www.glowm.com/section_view/heading/Substance%20Abuse%20in
%20Pregnancy/item/115
 Ariadna Forray 2016. Substance use during pregnancy. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4870985/#__ffn_sectitle
 Public Health (2019). The Influences of Drug Abuse on Mother-Infant Interaction Through
the Lens of the Biopsychosocial Model of Health and Illness: A Review. Retrieved from:
https://www.frontiersin.org/articles/10.3389/fpubh.2019.00045/full
 FETAL DISTRESS
I.DEFINTION/DESCRIPTION

 Fetal distress is an uncommon complication of labor. It typically occurs when the fetus has
not been receiving enough oxygen.
 Fetal distress may occur when
o The pregnancy lasts too long (postmaturity).
o Other complications of pregnancy or labor (such as difficult or rapid labor) occur.
 Usually, doctors identify fetal distress based on an abnormal heart rate pattern in the fetus.
Throughout labor, the fetus’s heart rate is monitored. It is usually monitored continuously
with electronic fetal heart monitoring. Or a handheld Doppler ultrasound device may be
used to check the heart rate every 15 minutes during early labor and after each contraction
during late labor.

II. INCIDENCE

Worldwide

According to Ajah, L.O,et.al.., (2016), Out of the 15,640 deliveries carried out within the
study period, 3,761 deliveries were through caesarean section thereby giving the caesarean section
rate as 24.05%. More so, a total of 326 caesarean sections were due to fetal distress within the study
period. Therefore fetal distress accounted for 8.9% of caesarean sections performed at the study
center. However, a total of 320 case files were retrieved thereby giving the retrieval rate of 98.2%.
All the patients with fetal distress were delivered through caesarean section. All of the pregnant
women were at term with the mean gestational age at 39±2 weeks.

Philippines

Perinatal morbidity was identified in 250 live births. Review of the maternal conditions giving
rise to a 25 percent or more rate of neonatal morbidity shows that multiple pregnancy was foremost
with a 60 percent rate, fetal distress with a 43 percent rate, premature rupture of membranes with a
38 percent rate, chronic toxemia with a 31 percent rate, and placenta previa with a 28 percent rate.

III. RISK FACTORS

Includes women with a history of:

 Stillbirth.
 Intrauterine growth restriction (IUGR).
 Oligohydramnios or polyhydramnios.
 Multiple pregnancy.
 Rhesus sensitisation.
 Hypertension.
 Obesity.
  Smoking.
 Diabetes and other chronic diseases.
 Pre-eclampsia or pregnancy-induced hypertension.
 Decreased fetal movements.
 Recurrent antepartum hemorrhage.
 Post-term pregnancy.

Maternal age over 35 years, and particularly over 40, is an independent risk factor for uteroplacental
insufficiency, fetal distress and stillbirth; the highest risk is in older women who are also nulliparous.

IV. MANIFESTATIONS

1. Decreased fetal movement in the womb

Fetal movement within the mother’s womb is one of the most exciting parts of pregnancy. Beyond
bringing joy to the family, movement within the womb is an important indicator of the baby’s
health. Some regular pauses in movement are normal because babies sleep in the womb. However,
if the baby becomes less active or completely ceases to move, this may be a cause for concern.
Physicians should ask expectant mothers about fetal movement and conduct additional testing if
patterns are abnormal.

2. Abnormal fetal heart rate

Some fetal heart rate patterns indicate distress. To observe an unborn baby’s heart rate, medical
professionals can use either an external or internal fetal monitoring device. External monitoring is
done through a belt-like device that can be strapped around a mother’s abdomen, while internal
monitoring involves attaching an electrode to the baby’s scalp. In a healthy labor and delivery, the
baby’s heart rate will drop slightly during a contraction, and then quickly return to normal once the
contraction is over. Therefore, some variability in heart rate is to be expected: this shows as a jagged
line on the monitor.

3. Abnormal amniotic fluid level

The amount of amniotic fluid can be determined using a variety of ultrasound methods, including a
qualitative assessment, the single deepest pocket (SDP), and the amniotic fluid index (AFI). The
qualitative assessment is fairly subjective. The ultrasonographer scans the uterus and reports
whether the amniotic fluid volume appears to be low, normal, or high, based on their own
experience. THE SDP, sometimes called the maximum vertical pocket (MVP), is the vertical
measurement (in centimeters) of the largest pocket of amniotic fluid that doesn’t contain parts of
the fetal body or umbilical cord. The AFI is calculated by measuring the depth of the amniotic fluid in
four sections of the womb and adding the numbers together.
If there is abnormally low amniotic fluid, this is a condition called oligohydramnios, which can lead to
oxygen deprivation and birth injuries like HIE and cerebral palsy (CP). A trending decrease in
amniotic fluid may also warn of oligohydramnios, and should be watched closely. If there is an
abnormally high amniotic fluid volume, this is known as polyhydramnios. Polyhydramnios can also
cause oxygen deprivation and subsequent birth injuries.

4. Abnormal results of biophysical profile (BPP)

A baby’s biophysical profile (BPP) is also often taken if the results of an NST are nonreassuring. In
addition to taking into account NST results, the BPP includes an ultrasound to assess fetal
movement, breathing, tone, and amniotic fluid volume. The nonstress test and each of the four
ultrasound parameters are assigned a score of either zero or two points (there is no one point). A
total score of eight or higher is considered normal, unless the zero score relates to low amniotic
fluid. A score of four or lower indicates fetal distress and requires immediate action.

5. Vaginal bleeding
Small amounts of vaginal bleeding are fairly common during pregnancy.  However, bleeding can be
an indication that something is wrong with the pregnancy. One particularly dangerous example is
placental abruption, which occurs when the placenta tears away from the womb. This causes the
baby to be deprived of oxygen.  Depending on the location and size of the abruption, it may not
initially cause fetal distress, but the health of both mother and baby could still be in jeopardy.
Likewise, it is important to note that a placental abruption can be present with no vaginal bleeding
(bleeding can be retained behind the placenta), but may still pose a serious risk.
A placental abruption and other placental problems that cause bleeding require very close
monitoring, and in many cases, the mother should be admitted to the hospital and given
an emergency C-section.

6. Cramping
Some cramping is relatively normal during pregnancy. This is because as the baby grows, the uterus
needs to expand. However, in some cases cramping is an indication of something more serious, such
as miscarriage, placental abruption, preeclampsia, a urinary tract infection, or preterm labor. It is
crucial that physicians appreciate cramping and perform proper tests to ensure the health of the
mother and baby.

7. Insufficient or excessive maternal weight gain

Experts believe that for women with a healthy pre-pregnancy weight, a weight gain of anywhere
between 25 and 35 pounds is normal during pregnancy.
If a mother gains much less than what is typical, the fetus may be in distress and have a condition
called intrauterine growth restriction (IUGR), which means they are smaller than is developmentally
appropriate (among other problems).  IUGR requires careful physician monitoring and testing, and
often early delivery prior to labor. A mother should have regular prenatal visits, and her physician
should know that abnormal weight changes may necessitate additional fetal monitoring.

V. MANAGEMENT
 Lab exam/diagnostic procedure

Fetal distress presents in varied ways and to differing degrees. It may be suspected by the following,
which may also be used for further evaluation of suspected fetal distress:

 Clinical suspicion when decreased fetal movements are felt by the mother or there is a
slowing or stopping of the growth of serial symphysis fundal height.
 Abnormal sonographic biometric parameters when IUGR or macrosomia is suspected.
 Doppler ultrasound is particularly valuable when performed up to 34 weeks of gestation:
o Umbilical artery Doppler may detect changes that reflect increasing placental
vascular resistance.
o Fetal arterial Doppler of, for example, the middle cerebral artery, may detect
reduced resistance which has developed to maintain blood flow to the fetal brain
when placental function is impaired.
o Fetal venous Doppler may detect changes indicative of impaired cardiac function
and fetal acidosis.
 Cardiotocography (CTG) shows the fetal heart rate response to fetal movement and to
maternal contractions. The trace it produces may be described as reassuring, non-reassuring
or abnormal:
 Antenatal CTG:
o A normal fetal heart rate accelerates with fetal movement and is described
as reactive.
o Stillbirth rates have been shown to be significantly lower after a reactive
trace than after a non-reactive trace.
o CTG interpretation is open to inter- and intra-observer variation but can be
interpreted by computerised analysis. CTG should not be used as the only
form of surveillance of a high-risk pregnancy.
o A contraction stress test, carried out during induced contractions using
oxytocin, has no clinical benefits, a false positive rate as high as 50% and
may have significant adverse effects.
 Intrapartum CTG:
o CTG should not be used routinely as part of the initial assessment of low-risk
women in early labour.
o No decision about a woman's care should be made on the basis of CTG
findings alone.
 Biophysical profile (BPP) is time-consuming and rarely abnormal in the presence of normal
umbilical arterial Doppler. It consists of a combination of CTG, fetal behaviour (including
movement, tone and breathing) and amniotic fluid volume. This produces a BPP score to
predict the degree of any compromise to the fetus. Available evidence does not support its
routine use in high-risk pregnancies but observational data suggest it has good negative
predictive value for fetal compromise.
  Amniotic fluid volume, both oligohydramnios and polyhydramnios, has been shown to be
associated with poor fetal outcomes. However, oligohydramnios is itself associated with
IUGR and urogenital malformations, which were not controlled for in the studies
demonstrating an association with poor outcomes. Polyhydramnios, when clinically
apparent, is related to poor neonatal outcomes but mild, idiopathic polyhydramnios,
detected only on ultrasound, is not associated with adverse outcomes.
 Fetal scalp blood sampling during labour, to measure lactate (in preference to pH if
available), may be indicated for an abnormal intrapartum CTG.

A composite risk score, based on fetal Doppler flow resistance indices, has shown promise in
identifying those fetuses antenatally who develop fetal distress intrapartum.

 Treatment/pharmacologic management
o Changing the mother’s position
o Ensuring the mother is well-hydrated
o Ensuring the mother has adequate oxygen
o Amnioinfusion (the insertion of fluid into the amniotic cavity to alleviate compression of the
umbilical cord)
o Tocolysis (a therapy used to delay preterm labor by temporarily stopping contractions)
o Intravenous hypertonic dextrose

 Nursing Responsibilities
 Assess maternal vital signs at least every 4 hours.
 Assess the character and amount of amniotic fluid (clear, bloody, meconium-stained, or
odorous).
 Assess the character and amount of blood show or vaginal bleeding.
 Assess maternal and fetal responses to labor.
 Assess the level of maternal discomfort and coping, and the effectiveness of pain
management as well as pain-relief measures.
 Determine, evaluate, and record intermittent auscultation, or review and document the
electronic fetal monitor (EFM) tracing of FHR every 30 minutes during the active phase
of the first stage of labor and at least every 15 minutes during the active, pushing phase
of the second stage of labor.
 Determine, evaluate, and record palpations of uterine activity, or review and document
the EFM tracing of uterine activity every 30 minutes during the active phase of the first
stage of labor and at least every 15 minutes during the active, pushing phase of the
second stage of labor.
 When complications occur or risk factors are present, the American Academy of
Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG)
suggest determining, evaluating, and recording intermittent auscultation or reviewing
 and documenting the EFM tracing of FHR at least every 15 minutes during the active
phase of the first stage of labor and at least every 5 minutes during the active, pushing
phase of the second stage of labor, preferably before, during, and after a uterine
contraction.
 Immediately after birth, assess maternal blood pressure and pulse at least every 15
minutes for 2 hours, or more frequently and for a longer period if complications occur;
assess maternal temperature at least every 4 hours for 8 hours after birth, and then at
least every 8 hours.
 If the patient received epidural anesthesia, assess maternal blood pressure after the
initiation or re-bolus of regional block medication, including patient-controlled epidural
anesthesia (PCEA), every 5 minutes for the first 15 minutes; then repeat every 30
minutes for 1 hour after the procedure.
 Assess FHR and uterine activity after the initiation or re-bolus of regional block
anesthesia, including PCEA, every 5 minutes for the first 15 minutes.
 Assess the neonate's Apgar scores at 1 minute and 5 minutes after birth.
 If the neonate has an Apgar score of less than 7, assess the Apgar score every 5 minutes
up to 20 minutes.
 Assess and record the neonate's temperature, heart rate, respiratory rate, type of
respiration, skin color, adequacy of peripheral circulation, muscle tone, level of
consciousness, and activity at least every 30 minutes until the neonate's condition has
remained stable for at least 2 hours.

References

 Payne (2016). Fetal distress. Retrieved from: https://patient.info/doctor/fetal-distress

 Reiter & Walsh, P.C. (n.d.). What Signs Indicate My Baby Is In Distress? How Is Fetal Distress Treated?.
Retrieved from: https://www.abclawcenters.com/frequently-asked-questions/what-are-some-
signs-that-my-baby-is-in-distress/

 American pregnancy association (n.d.). Fetal Distress: Diagnosis, Conditions & Treatment.

Retrieved from: https://americanpregnancy.org/labor-and-birth/fetal-distress/
 INFERTILITY AND SEXUAL DYSFUNCTION
I. DEFINTION/DESCRIPTION
INFERTILITY
 Infertility happens when a couple cannot conceive after having regular unprotected sex.
 It may be that one partner cannot contribute to conception, or that a woman is unable to
carry a pregnancy to full term. It is often defined as not conceiving after 12 months of
regular sexual intercourse without the use of birth control.

SEXUAL DYSFUNCTION
  Sexual dysfunction disorders can be described as an impairment or disturbance in any of the
phases of the sexual response cycle.

II. INCIDENCE
 Infertility- Worldwide, 8 to 12 percent of couples experience fertility problems. Between 45
and 50 percent of cases are thought to stem from factors that affect the man.
 Sexual dysfunction- The prevalence of sexual dysfunction increases as men and women age;
about 40-45% of adult women and 20-30% of adult men have at least one manifest sexual
dysfunction.

III. RISK FACTORS

INFERTILITY IN MEN

 Sulfasalazine: This anti-inflammatory drug can significantly lower a man's sperm count. It is
often prescribed for Crohn's disease or rheumatoid arthritis. Sperm count often returns to
normal after stopping the medication.
 Anabolic steroids: Popular with bodybuilders and athletes, long-term use can seriously
reduce sperm count and mobility.
 Chemotherapy: Some types may significantly reduce sperm count.
 Illegal drugs: Consumption of marijuana and cocaine can lower the sperm count.
 Age: Male fertility starts to fall after 40 years.
 Exposure to chemicals: Pesticides, for example, may increase the risk.
 Excess alcohol consumption: This may lower male fertility. Moderate alcohol consumption
has not been shown to lower fertility in most men, but it may affect those who already have
a low sperm count.
 Overweight or obesity: This may reduce the chance of conceiving.
 Mental stress: Stress can be a factor, especially if it leads to reduced sexual activity.

INFERTILITY IN WOMEN

 Age: The ability to conceive starts to fall around the age of 32 years.
 Smoking: Smoking significantly increases the risk of infertility in both men and women, and it
may undermine the effects of fertility treatment. Smoking during pregnancy increases the
chance of pregnancy loss. Passive smoking has also been linked to lower fertility.
 Alcohol: Any amount of alcohol consumption can affect the chances of conceiving.
 Being obese or overweight: This can increase the risk of infertility in women as well as men.
 Eating disorders: If an eating disorder leads to serious weight loss, fertility problems may
arise.
 Diet: A lack of folic acid, iron, zinc, and vitamin B-12 can affect fertility. Women who are at
risk, including those on a vegan diet, should ask the doctor about supplements.
 Exercise: Both too much and too little exercise can lead to fertility problems.
 Sexually transmitted infections (STIs): Chlamydia can damage the fallopian tubes in a woman
and cause inflammation in a man's scrotum. Some other STIs may also cause infertility.
 Exposure to some chemicals: Some pesticides, herbicides, metals, such as lead, and solvents
have been linked to fertility problems in both men and women. A mouse study has
suggested that ingredients in some household detergents may reduce fertility.
  Mental stress: This may affect female ovulation and male sperm production and can lead to
reduced sexual activity.
 Ovulation disorders appear to be the most common cause of infertility in women.
Ovulation is the monthly release of an egg. The eggs may never be released or they may only
be released in some cycles.
Ovulation disorders can be due to:
o Premature ovarian failure: The ovaries stop working before the age of 40 years.
o Polycystic ovary syndrome (PCOS): The ovaries function abnormally and
ovulation may not occur.
o Hyperprolactinemia: If prolactin levels are high, and the woman is not pregnant or
breastfeeding, it may affect ovulation and fertility.
o Poor egg quality: Eggs that are damaged or develop genetic abnormalities cannot
sustain a pregnancy. The older a woman is, the higher the risk.
o Thyroid problems: An overactive or underactive thyroid gland can lead to a
hormonal imbalance.
o Chronic conditions: These include AIDS or cancer.
 Problems in the uterus or fallopian tubes can prevent the egg from traveling from the ovary
to the uterus, or womb.
If the egg does not travel, it can be harder to conceive naturally.
Causes include:
o Surgery: Pelvic surgery can sometimes cause scarring or damage to the fallopian
tubes. Cervical surgery can sometimes cause scarring or shortening of the cervix. The
cervix is the neck of the uterus.
o Submucosal fibroids: Benign or non-cancerous tumors occur in the muscular wall of
the uterus. They can interfere with implantation or block the fallopian tube,
preventing sperm from fertilizing the egg. Large submucosal uterine fibroids may
make the uterus' cavity bigger, increasing the distance the sperm has to travel.
o Endometriosis: Cells that normally occur within the lining of the uterus start growing
elsewhere in the body.
o Previous sterilization treatment: In women who have chosen to have their fallopian
tubes blocked, the process can be reversed, but the chances of becoming fertile
again are not high.

SEXUAL DYSFUNCTION

 Common risk factor categories associated with sexual dysfunction exist for men and women
including:
o individual general health status
o diabetes mellitus
o cardiovascular disease
o other genitourinary disease
o psychiatric/psychological disorders
o other chronic diseases, and
o socio-demographic conditions. 

IV. MANIFESTATIONS
INFERTILITY

 Sometimes, female infertility is related to a hormone problem. In this case, symptoms can

also include:
o Skin changes, including more acne
o Changes in sex drive and desire
o Dark hair growth on the lips, chest, and chin
o Loss of hair or thinning hair
o Weight gain
 Other symptoms of disorders that may lead to infertility include:
o Milky white discharge from nipples unrelated to breastfeeding
o Pain during sex
 Many other things can be related to infertility in women, and their symptoms vary.

SEXUAL DYSFUNCTION

 Absence of sexual fantasies and desire for sexual activity.

 Discrepancy between partners’ levels of desire for sexual activity.
 Feelings of disgust, anxiety, or panic responses to genital contact.
 Inability to produce adequate lubrication for sexual activity.
 Absence of a subjective sense of sexual excitement during sexual activity.
 Failure to attain or maintain penile erection until completion of sexual activity.
 Inability to achieve orgasm (in men, to ejaculate) following a period of sexual excitement
judged adequate in intensity and duration to produce such a response.
 Ejaculation occurs with minimal sexual stimulation or before, on, or shortly after penetration
and before the individual wishes it.
 Genital pain occurring before, during, or after sexual intercourse.
 Constriction of the outer third of the vagina prevents penile penetration.

V. MANAGEMENT
 Lab exam/diagnostic procedure

Infertility tests for men

 The doctor will ask the man about his medical history, medications, and sexual habits and
carry out a physical examination. The testicles will be checked for lumps or deformities, and
the shape and structure of the penis will be examined for abnormalities.
o Semen analysis: A sample may be taken to test for sperm concentration, motility,
color, quality, any infections, and whether any blood is present. Sperm counts can
fluctuate, so that several samples may be necessary.
o Blood test: The lab will test for levels of testosterone and other hormones.
o Ultrasound: This may reveal issues such as ejaculatory duct obstruction or
retrograde ejaculation.
o Chlamydia test: Chlamydia can affect fertility, but antibiotics can treat it.

Infertility tests for women

  A woman will undergo a general physical examination, and the doctor will ask about her
medical history, medications, menstruation cycle, and sexual habits.
She will also undergo a gynecologic examination and a number of tests:
o Blood test: This can assess hormone levels and whether a woman is ovulating.
o Hysterosalpingography: Fluid is injected into the woman's uterus and X-rays are
taken to determine whether the fluid travels properly out of the uterus and into the
fallopian tubes. If a blockage is present, surgery may be necessary.
o Laparoscopy: A thin, flexible tube with a camera at the end is inserted into the
abdomen and pelvis, allowing a doctor to look at the fallopian tubes, uterus, and
ovaries. This can reveal signs of endometriosis, scarring, blockages, and some
irregularities of the uterus and fallopian tubes.

Other tests include:

o ovarian reserve testing, to find out how effective the eggs are after ovulation genetic testing,
to see if a genetic abnormality is interfering with fertility
o pelvic ultrasound, to produce an image of the uterus, fallopian tubes, and ovaries
o Chlamydia test, which may indicate the need for antibiotic treatment thyroid function test,
as this may affect the hormonal balance

SEXUAL DYSFUNCTION

 gathering a health and sexual history , performing a physical exam and discussing symptoms
and concerns. The doctor may also recommend some diagnostic tests in order to find or
rule out medical conditions that could be causing or contributing sexual dysfunction.
 The doctor may also ask questions to evaluate things like the client’s  thoughts and attitudes
about sex and sexuality and may ask the client whether she/he have any fear, anxiety or past
trauma that could lead to sexual dysfunction. 

 Treatment/pharmacologic management

INFERTILITY

Treatments for men

 Treatment will depend on the underlying cause of the infertility.

o Erectile dysfunction or premature ejaculation: Medication, behavioral approaches,
or both may help improve fertility.
o Varicocele: Surgically removing a varicose vein in the scrotum may help.
o Blockage of the ejaculatory duct: Sperm can be extracted directly from the testicles
and injected into an egg in the laboratory.
o Retrograde ejaculation: Sperm can be taken directly from the bladder and injected
into an egg in the laboratory.
o Surgery for epididymal blockage: A blocked epididymis can be surgically repaired.
The epididymis is a coil-like structure in the testicles which helps store and transport
sperm. If the epididymis is blocked, sperm may not be ejaculated properly.

Treatments for women

 Fertility drugs might be prescribed to regulate or induce ovulation.

 They include:
o Clomifene (Clomid, Serophene): This encourages ovulation in those who ovulate
either irregularly or not at all, because of PCOS or another disorder. It makes the
pituitary gland release more follicle-stimulating hormone (FSH) and luteinizing
hormone (LH).
o Metformin (Glucophage): If Clomifene is not effective, metformin may help women
with PCOS, especially when linked to insulin resistance.
o Human menopausal gonadotropin, or hMG (Repronex): This contains both FSH and
LH. Patients who do not ovulate because of a fault in the pituitary gland may receive
this drug as an injection.
o Follicle-stimulating hormone (Gonal-F, Bravelle): This hormone is produced by the
pituitary gland that controls estrogen production by the ovaries. It stimulates the
ovaries to mature egg follicles.
o Human chorionic gonadotropin (Ovidrel, Pregnyl): Used together with clomiphene,
hMG, and FSH, this can stimulate the follicle to ovulate.
o Gonadotropin-releasing hormone (Gn-RH) analogs: These can help women who
ovulate too early—before the lead follicle is mature—during hmG treatment. It
delivers a constant supply of Gn-RH to the pituitary gland, which alters the
production of hormone, allowing the doctor to induce follicle growth with FSH.
o Bromocriptine (Parlodel): This drug inhibits prolactin production. Prolactin
stimulates milk production during breastfeeding. Outside pregnancy and lactation,
women with high levels of prolactin may have irregular ovulation cycles and fertility
problems.

SEXUAL DYSFUNCTION

 Most types of sexual dysfunction can be corrected by treating the underlying physical or
psychological problems. Other treatment strategies include:
o Medication — When a medication is the cause of the dysfunction, a change in the
medication may help. Men and women with hormone deficiencies may benefit from
hormone shots, pills, or creams. For men, drugs, including sildenafil (Viagra®),
tadalafil (Cialis®), vardenafil (Levitra®, Staxyn®), and avanafil (Stendra®) may help
improve sexual function by increasing blood flow to the penis.
o Mechanical aids — Aids such as vacuum devices and penile implants may help men
with erectile dysfunction (the inability to achieve or maintain an erection). A vacuum
device (Eros) is also approved for use in women, but can be costly. Dilators may help
women who experience narrowing of the vagina.
o Sex therapy — Sex therapists can be very helpful to couples experiencing a sexual
problem that cannot be addressed by their primary clinician. Therapists are often
good marital counselors, as well. For the couple who wants to begin enjoying their
sexual relationship, it is well worth the time and effort to work with a trained
professional.
o Behavioral treatments — These involve various techniques, including insights into
harmful behaviors in the relationship, or techniques such as self-stimulation for
treatment of problems with arousal and/or orgasm.
o Psychotherapy — Therapy with a trained counselor can help a person address sexual
trauma from the past, feelings of anxiety, fear, or guilt, and poor body image, all of
which may have an impact on current sexual function.
 o Education and communication — Education about sex and sexual behaviors and
responses may help an individual overcome his or her anxieties about sexual
function. Open dialogue with your partner about your needs and concerns also helps
to overcome many barriers to a healthy sex life.

 Nursing Responsibilities

INFERTILITY

 Treat patients with infertility

 Assist female patients going through menopause

 Counsel patients and their loved ones on fertility

 Work with researchers on the latest reproductive technologies

 Help patients understand procedures and medical terminology

 Offer patients non-judgmental emotional support

 Administer In-Vitro Fertilization (IVF) treatments

 Teach patients how to administer IVF treatments

 Counseling couples and donors throughout the entire process

 Educate patients about various available treatments and the positives and negatives of each

SEXUAL DYSFUNCTION

 Determine stressors. Help client determine time dimension associated with the onset of the
problem and discuss what was happening in his or her life situation at that time.
 Encourage discussion of disease process. Encourage client to discuss disease process that
may be contributing to sexual dysfunction; ensure that client is aware that alternative
methods of achieving sexual satisfaction exist and can be learned through sex counseling if
he or she and partner desire to do so.
 Identify factors that affect client’s sexuality. Note cultural, social, ethnic, racial, and religious
factors that may contribute to conflicts regarding variant sexual practices.
 Be accepting and nonjudgmental. Sexuality is a very personal and sensitive subject; the
client is more likely to share this information if he or she does not fear being judged by
the nurse.
 Provide positive reinforcement. Observe client behaviors and the responses he or she elicits
from others; give social attention (e.g., smile, nod) to desired behaviors.

REFERENCES:
 Sexual Dysfunction and Infertility.(2015). Retrieved from
https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-
booklets/documents/fact-sheets-and-info-booklets/sexual-dysfunction-and-infertility/ on January
28, 2020.

Lewis RW, et al. J Sex Med. 2004. Epidemiology/risk factors of sexual dysfunction. Retrieved
from https://www.ncbi.nlm.nih.gov/m/pubmed/16422981/ on January 28, 2020.

Male infertility. (2018). Retrieved from https://www.mayoclinic.org/diseases-

conditions/male-infertility/symptoms-causes/syc-20374773 on January 28, 2020.

Female infertility. (2019). Rettieved from https://www.mayoclinic.org/diseases-

conditions/female-infertility/symptoms-causes/syc-20354308 on January 28, 2020.

What Is a Fertility Nurse?, (2019). Retrieved from

https://www.registerednursing.org/specialty/fertility-nurse/ on January 28, 2020.

PEDIA
ABO COMPATIBILITY
I. DEFINITION/DESCRIPTION

Isoimmune hemolytic anemia may result when ABO incompatibility occurs between the mother and
the newborn infant. This disorder is most common with blood type A or B infants born to type O
mothers. The hemolytic process begins in utero and is the result of active placental transport of
maternal isoantibody. In type O mothers, isoantibody is predominantly 7S-IgG (immunoglobulin G)
and is capable of crossing the placental membranes. Because of its larger size, the mostly 19S-IgM
(immunoglobulin M) isoantibody found in type A or type B mothers cannot cross. Symptomatic
clinical disease, which usually does not present until after birth, is a compensated mild hemolytic
anemia with reticulocytosis, microspherocytosis, and early-onset unconjugated hyperbilirubinemia.

II. INCIDENCE

ABO incompatibility frequently occurs during the first pregnancy and is present in approximately
12% of pregnancies, with evidence of fetal sensitization in 3% of live births. Less than 1% of births
are associated with significant hemolysis.

The population in Singapore is predominantly Asian, with Chinese forming the major ethnic group.
The incidence of hemolytic disease of the newborn (HDN) due to Rh incompatibility is very low. The
true incidence of HDN due to ABO incompatibility is unknown. Early discharge is practiced in
Singapore making it important to predict severe HDN due to ABO incompatibility as this would
constitute the main cause of hemolysis next to G6PD deficiency. One thousand, six hundred and
eight baby-maternal pairs were typed for ABO, Rh, and tested for direct Coombs' test, maternal titre,
cord bilirubin and haptoglobin levels. Two hundred and fifty-one were found to be ABO
incompatible, with 141 group A and 110 group B babies. The incidence of HDN due to ABO
incompatibility was 3.7% of all group O mothers. Coombs' test, maternal antibody titre, cord
bilirubin and haptoglobin levels were of low predictive value for severe HDN due to ABO
incompatibility. The data further support the notion that it is not cost effective to screen for ABO
incompatibility.

ABO hemolytic disease of the newborn is the most common hemolytic consequence of maternofetal
blood group incompatibility restricted mostly to non-group-O babies of group O mothers with
immune anti-A or anti-B antibodies.

III. RISK FACTORS

A. A1 antigen in the infant. Of the major blood group antigens, the A1 antigen has the greatest
antigenicity and is associated with a greater risk of symptomatic disease. However, the
hemolytic activity of anti-B antibodies is higher than those of anti-A and may produce a more
severe disease in particular among infants of African American descent.
B. Elevated isohemagglutinins. Antepartum intestinal parasitism or third-trimester
immunization with tetanus toxoid or pneumococcal vaccine may stimulate isoantibody titer
to A or B antigens.
C. Birth order. Birth order is not considered a risk factor. Maternal isoantibody exists naturally
and is independent of prior exposure to incompatible fetal blood group antigens. First-born
infants have a 40–50% risk for symptomatic disease. Progressive severity of the hemolytic
process in succeeding pregnancies is a rare phenomenon.

IV. MANIFESTATIONS

The following are symptoms of ABO incompatible transfusion reactions:

 Back pain

 Blood in urine
  Chills

 Feeling of "impending doom"

 Fever

 Yellow skin (jaundice)

V. MANAGEMENT

 Lab exam/diagnostic procedure

The health care provider will perform a physical exam. Blood tests will usually show:

 Bilirubin level is high

 Complete blood count (CBC) shows damage to red blood cells or anemia
 The patient's and donor's blood are not compatible

Urine tests show the presence of hemoglobin due to breakdown of red blood cells.

 Treatment/ pharmacologic management

Treatment may include:

 Drugs used to treat allergic reactions (antihistamines)

 Drugs used to treat swelling and allergies (steroids)
 Fluids given through a vein (intravenously)
 Medicines to raise blood pressure if it drops too low

 Nursing Responsibilities
 Keep infant warm and dry.
 Monitor skin and body temperature frequently.
 Monitor laboratory studies as indicated such as hematology, and direct and indirect
bilirubin.
 Initiate phototherapy per protocol, using fluorescent bulbs placed above the infant or
bili blanket.
 Discontinue breastfeeding for 24-48 hours as indicated. Assist mother as needed with
pumping of breasts and reestablishment of breastfeeding.
 Assist with preparation and administration of exchange transfusion if needed.
 Regarding in phototherapy, apply patches to closed eyes. Inspect eyes every 2 hours
when patches are removed for feedings.
 Monitor fluid intake and output; weigh infant twice a day. Note signs of dehydration
(reduced urine output, depressed fontanels, dry or warm skin with poor skin turgor and
sunken eyes).
  Increased oral fluid intake by at least 25%.

References

 Bass (2019). Blood Type Incompatibility, Rh Incompatibility, and Jaundice. Retrieved from:
https://www.cerebralpalsyguidance.com/cerebral-palsy/risk-factors/blood-type-
incompatibility/

 Tricia Lacy Gomella (n.d.). Neonatology: Management, Procedures, On-Call Problems,

Diseases, and Drugs, 7e. Retrieved from:
https://accesspediatrics.mhmedical.com/book.aspx?bookid=1303

 Nicklaus Children’s Hospital (n.d.). ABO incompatibility. Retrieved from:

https://www.nicklauschildrens.org/blood/abo-incompatibility.aspx

GASTROESOPHAGEAL ACID REFLUX

I. DEFINITION
 Gastroesophageal reflux (GER) is when the esophageal sphincter is relaxed and allows
gastric contents to be regurgitated back into the esophagus.
 In pediatric gastroesophageal reflux, immaturity of lower esophageal sphincter (LES)
function is manifested by frequent transient lower esophageal relaxations (tLESRs),
which result in the retrograde flow of gastric contents into the esophagus.
 Thus, gastroesophageal reflux represents a common physiologic phenomenon in the first
year of life; as many as 60-70% of infants experience emesis during at least 1 feeding per
24-hour period by age 3-4 months.
 II. INCIDENCE

Although minor degrees of gastroesophageal reflux are noted in children and adults, the
degree and severity of reflux episodes are increased during infancy.

 Gastroesophageal reflux is most commonly seen in infancy, with a peak at age 1-

4 months; however, it can be seen in children of all ages, even healthy
teenagers.
 Approximately 85% of infants vomit during the first week of life, and 60-70%
manifest clinical gastroesophageal reflux at age 3-4 months.
 Symptoms abate without treatment in 60% of infants by age 6 months, when
these infants begin to assume an upright position and eat solid foods.
 Resolution of symptoms occurs in approximately 90% of infants by age 8-10
months.

III. RISK FACTORS

GERD is very common during a baby’s first year of life. It often goes away on its own. The child is
more at risk for GERD if he or she has:

 Down syndrome
 Neuromuscular disorders such as muscular dystrophy and cerebral palsy.

IV. MANIFESTATIONS
 The symptoms of gastroesophageal reflux are most often directly related to the
consequences of emesis (e.g., poor weight gain) or result from exposure of the esophageal
epithelium to the gastric contents.
o Heartburn. Heartburn is more common in adults, and children have a harder time
describing this sensation; they usually will complain of a stomach ache or chest
discomfort, particularly after meals.
o Dental problems. In toddlers and older children, excessive regurgitation may lead to
significant dental problems caused by acid effects on tooth enamel.
o Esophagitis. Esophagitis may manifest as crying and irritability in the nonverbal
infant.
o Failure to thrive. Failure to thrive can result from insufficient caloric intake
secondary to repeated vomiting and nutrient losses from emesis.
o Regurgitation. Frequent regurgitation or vomiting after especially after meals occurs
when there is a resistance to the gastric outflow.

V. MANAGEMENT
 LAB EXAM / DIAGNOSTIC PROCEDURE
In most cases of gastroesophageal reflux, the diagnosis can be made from the history and physical
examination.
 o Manometry. This is becoming a more accessible tool for use in infants and children; it is used
to assess esophageal motility and lower esophageal sphincter (LES) function.
o Esophagogastroduodenoscopy. This modality is useful in patients who are unresponsive to
medical therapy; it allows for visualization of the mucosa for diagnosis of peptic ulcer
disease, Helicobacter pylori infection, strictures, and peptic esophagitis.
o Histologic findings. Histologic signs of peptic esophagitis include basal cell hyperplasia,
extended papillae, and mucosal eosinophils.
o Upper GI imaging series. Such studies are used to evaluate the anatomy of the upper
gastrointestinal (GI) tract, but contrast imaging is neither sensitive nor specific for
gastroesophageal reflux.
o Gastric scintiscan. A gastric scintiscan study, using milk or formula that contains a small
amount of technetium sulfur colloid, can assess gastric emptying and reveal reflux (although
not the degree or severity of it).
o Esophagography. Esophagography, conducted under fluoroscopic control, may reveal the
integrity of esophageal peristalsis; however, it should not be used to assess the degree and
severity of gastroesophageal reflux.
o Intraesophageal pH probe monitoring. A continuous esophageal pH probe in the distal
esophagus documents the severity and frequency of reflux.
o Intraluminal esophageal electrical impedance. Intraluminal esophageal electrical impedance
(EEI) is useful for detecting both acid reflux and nonacid reflux by measuring retrograde flow
in the esophagus.

 TREATMENT/ PHARMACOLOGIC MANANGEMENT

Results of medical therapy is generally met with a better long-term response, leading to the
elimination of antisecretory medications (when prescribed) during infancy.

 Positioning. Infants and children diagnosed with gastroesophageal reflux should avoid the
seated or the supine position shortly after meals; prone positioning may be recommended
for the patient, at least for the first postprandial hour; sleeping in the prone position has
been demonstrated to decrease the frequency of gastroesophageal reflux.
 Dietary measures.
o Thickening an infant’s formula provides a therapeutic advantage against
gastroesophageal reflux, particularly when excessive vomiting is associated with
suboptimal weight gain; younger formula-fed infants may benefit from a pre-
thickened, proprietary formula (e.g., Enfamil-AR; Mead-Johnson Nutritionals Inc,
Evansville, IN);
o For breastfed infants. Aside from increasing feeding frequency, expressed breast
milk may be thickened as described; in addition, early introduction of rice cereal
feedings (at age three (3) months) may be attempted;
o For children. Small, frequent meals are also recommended; greasy and spicy foods,
which encourage postprandial reflux by increasing gastric distention and slowing
gastric emptying, should be avoided; chocolate, peppermint, tomato products,
citrus, and caffeine, which lowers LES pressure, should also be avoided.
 Step-up and step-down therapy. Guidelines from the North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition (NASPGHAN) discuss the use of step-up and
step-down therapies, which should be instituted under the guidance of a pediatric
gastroenterologist; in the case of pharmacologic intervention, step-up therapy involves
 progression from diet and lifestyle changes to H2 -receptor blockade medications (eg,
ranitidine, nizatidine) to proton pump inhibitors (eg, omeprazole, lansoprazole).
 Fundoplication. The goal of surgery for patients with GERD is to reestablish the antireflux
barrier without creating an obstruction to the food bolus; in general, the Nissen
fundoplication, which is a complete 360° wrap, best controls the symptoms of
gastroesophageal reflux.

Pharmacologic Management

A therapeutic response to treatment for gastroesophageal reflux may take up to 2 weeks.

 Antacids. These agents are used as diagnostic tools to provide symptomatic relief in infants;
associated benefits include symptomatic alleviation of constipation (aluminum antacids)
or loose stools (magnesium antacids).
 Histamine H2 antagonists. Like antacids, these agents do not reduce the frequency of reflux
but do decrease the amount of acid in the refluxate by inhibiting acid production; all H2
-receptor antagonists are equipotent when used in equivalent doses; they are most effective
in patients with nonerosive esophagitis; H2 -receptor antagonists are considered the drugs
of choice for children because pediatric doses are well established and the medications are
available in liquid form.
 Proton pump inhibitors. These agents are indicated in patients who require complete acid
suppression (eg, infants with chronic respiratory disease or neurologic disabilities);
administer proton pump inhibitors with the first meal of the day; children with nasogastric
or gastrostomy tubes may have granules mixed with an acidic juice or a suspension; tubes
must then be flushed to prevent blockage.

 NURSING RESPONSIBILITIES
1. Improve nutrition. Accurately measure the patient’s weight and height; encourage small
frequent meals of high calories and high protein foods; instruct to remain in upright position
at least 2 hours after meals; avoiding eating 3 hours before bedtime; instruct patient to eat
slowly and masticate foods well; establish a dietary plan for weekly goals of weight loss of
one pound; encourage patient to make gradual changes in dietary habits; provide activities
for the patient that do not center around or are associated with meals or snacks.
2. Relieve pain. Assess for heartburn, and carefully assess pain location and discern pain from
GERD and angina pectoris.
3. Prevent aspiration. Avoid placing the patient in supine position, have the patient sit upright
after meals; instruct patient to avoid highly seasoned food, acidic juices, alcoholic drinks,
bedtime snacks, and foods high in fat; elevate HOB while in bed.
4. Enforce health education. Provide patient and folks with information regarding disease
process, health practices that can be changed, and medications to be utilized; instruct
patient and folks in medications, effects, side effects, and to report to physician if symptoms
persist despite medical treatment.
5. Relieve anxiety. Allow verbalization of concerns and to ask inquiries about illness, treatment,
surgery, recovery by parents; encourage parents to stay with the child
and to assist in care; communicate frequently with parents and provide easy to understand
and truthful answers to questions; utilize pictures, drawings, and models for explanations.
6. Prevent injury. Inform parents that infant usually outgrows the disorder and attains normal
function by 6 weeks of age and those with a persistent reflux problem usually resolve by 6
 months of age; assist and prepare parents and infant for diagnostic examination and
possible surgical procedure; educate and instruct to do Guaiac test on stool and vomitus and
allow to return demonstration.

REFERENCES:

Retrieved from www.nurseslab/gastroesophageal-reflux, retrieved on January 31, 2020

CEREBRAL PALSY
I. DEFINITION/ DESCRIPTION

Cerebral palsy is one of the most complex of the common permanent disabling conditions.

 Research in this area is directed at adapting biomedical technology to help people with
cerebral palsy cope with the activities of daily living and achieve maximum function and
independence.
 Cerebral palsy is a disorder of movement, muscle tone or posture that is caused by damage
that occurs to the immature, developing brain, most often before birth.

 Classification

Several major types of cerebral palsy occur; each has distinctive clinical manifestations.
  Spastic type. Spastic cerebral palsy is the most common type and is characterized by a
hyperactive stretch reflex, clonus (rapid involuntary muscle contraction and relaxation,
contractures, scissoring (when scissoring is present, the child’s legs are crossed and the toes
are pointed down.
 Athetoid type. Athetoid cerebral palsy is marked by involuntary, uncoordinated motion with
varying degrees of muscle tension; children with this disorder are constantly in motion, and
the whole body is in a state of slow, writhing muscle contractions whenever voluntary
movement is attempted.
 Ataxic type. Ataxia is essentially a lack of coordination caused by disturbances in the
kinesthetic and balance senses; ataxic cerebral palsy may not be diagnosed until the child
starts to walk; the gait is awkward and wide-based.
 Rigidity type. Rigidity cerebral palsy is uncommon and is characterized by rigid postures and
lack of active movement.
 Mixed type. Children with signs of more than one type of cerebral palsy, turned mix type,
are usually disabled; the disorder may have been caused by postnatal injury.

II. INCIDENCE

The incidence of cerebral palsy have not changed in more than 4 decades, despite significant
advances in the medical care of neonates.

 In developed countries, the overall estimated prevalence of cerebral palsy is 2-2.5 cases per
1000 live births.
 In the developing world, the prevalence of cerebral palsy is not well established but
estimates are 1.5-5.6 cases per 1000 live births.
 Lower socioeconomic status and male sex may be increased risk factors for cerebral palsy.
 Approximately 30-50% of patients with cerebral palsy have mental retardation, depending
on the type.
 Approximately 15-60% of children with cerebral palsy have epilepsy, and epilepsy is more
frequent in patients with spastic quadriplegia or mental retardation.

III. RISK FACTORS

Some events or medical problems during pregnancy can increase the risk of congenital cerebral
palsy. These risk factors include
 Low birth weight or preterm birth. Infants born preterm (defined as before 37 weeks of
pregnancy) and infants who weigh less than 5.5 pounds at birth are at greater risk of
cerebral palsy than are early term (defined as 37 weeks to 38 weeks of pregnancy) and full-
term (defined as 39 weeks to 40 weeks of pregnancy) infants and those who are heavier at
birth. The earlier the birth and the lower the infant’s birthweight, the greater the risk.
 Multiple gestations. Twins, triplets, and other multiple births are at higher risk of cerebral
palsy. The risk is also greater for an infant whose twin or triplet dies before or shortly after
birth.
 Infertility treatments. Infants born from pregnancies resulting from the use of certain
infertility treatments are at higher risk for cerebral palsy than are infants born from
pregnancies not related to infertility treatments. Much of this increased risk may be due to
the fact that infertility treatments are more likely to result in preterm delivery and multiple
gestations.
  Infections during pregnancy. Toxoplasmosis, rubella (German measles), cytomegalovirus,
and herpes can infect the womb and placenta, leading to brain damage in the fetus.
 Fever during pregnancy. Sometimes fever in the mother during pregnancy or delivery can
lead to brain damage in the fetus, resulting in cerebral palsy.
 Blood factor between mother and fetus does not match. Those who have a certain protein
found on red blood cells—abbreviated Rh—are Rh positive; those who do not have the
protein are Rh negative. If a mother’s Rh factor is different from that of the fetus, her
immune system may attack the blood cells of the fetus, including blood cells in the brain,
which can lead to brain damage.
 Exposure to toxic chemicals. If a mother is exposed to a toxic substance, such as high levels
of methyl mercury (found in some thermometers and in some seafood), during pregnancy
the fetus is at higher risk of cerebral palsy.
 Maternal medical conditions:
o Abnormal thyroid function
o Intellectual and developmental disability
o Too much protein in the urine
o Seizures
 Complicated labor and delivery. Infant heart or breathing problems during labor and delivery
and immediately after birth increase the risk of cerebral palsy.
 Jaundice (pronounced JAWN-dis). Jaundice, which causes an infant’s skin, eyes, and mouth
to turn a yellowish color, can be a sign that the liver is not working normally. Jaundice occurs
when a substance called bilirubin (pronounced BIL-uh-roo-bin) builds up faster than the liver
can clear it from the body. This condition is common and is usually not serious. However, in
cases of severe, untreated jaundice, the excess bilirubin can damage the brain and cause
cerebral palsy.
 Seizures. Infants who have seizures are more likely to be diagnosed with cerebral palsy later
in childhood.
IV. MANIFESTATIONS

Signs of cerebral palsy include the following:

 Developmental delay. History of gross motor developmental delay in the first year of life.
 Abnormal muscle tone. The most frequently observed symptom; the child may present as
either hypotonic or, more commonly, hypertonic, with either decreased or increased
resistance to passive movements, respectively; children with cerebral palsy may have an
early period of hypotonia followed by hypertonia; a combination of axial hypotonia and
peripheral hypotonia is indicative of a central process.
 Hand preference. Definite hand preference before age 1 year: A red flag for possible
hemiplegia.
 Problems in crawling. Asymmetrical crawling or failure to crawl.
 Growth disturbance. There is a growth disturbance especially in failure to thrive.
 Increased reflexes. Indicating the presence of an upper motor neuron lesion; this condition
may also present as the persistence of primitive reflexes.
 Problems in reflexes. Underdevelopment or absence of postural or protective reflexes.

V. MANAGEMENT
 LAB EXAM / DIAGNOSTIC PROCEDURE
The diagnosis of cerebral palsy is generally made based on the clinical picture; there are no definitive
laboratory studies for diagnosing the condition, only studies, including the following, to rule out
other symptom causes:

 Thyroid function studies. Abnormal thyroid function may be related to abnormalities in

muscle tone or deep tendon reflexes or to movement disorders.
 Lactate and pyruvate levels. Abnormalities may indicate an abnormality of energy
metabolism (ie, mitochondrial cytopathy).
 Ammonia levels. Elevated ammonia levels may indicate liver dysfunction or urea cycle
defect.
 Organic and amino acids. Serum quantitative amino acid and urine quantitative organic acid
values may reveal inherited metabolic disorders.
 Chromosomal analysis. Chromosomal analysis, including karyotype analysis and specific DNA
testing, may be indicated to rule out a genetic syndrome if dysmorphic features or
abnormalities of various organ systems are present.
 Cerebrospinal protein. Levels may assist in determining asphyxia in the neonatal period;
protein levels can be elevated, as can the lactate-to-pyruvate ratio.
 Cranial ultrasonography. Can be performed in the early neonatal period to delineate clear-
cut structural abnormalities and show evidence of hemorrhage or hypoxic-ischemic injury.
 Computed tomography scanning of the brain. In infants, helps to identify congenital
malformations, intracranial hemorrhage, and periventricular leukomalacia or early
craniosynostosis.
 Magnetic resonance imaging of the brain. The diagnostic neuroimaging study of choice
because this modality defines cortical and white matter structures and abnormalities more
clearly than does any other method; MRI also allows for the determination of whether
appropriate myelination is present for a given age.

 TREATMENT/ PHARMACOLOGIC MANANGEMENT

Treatment of cerebral palsy focuses on helping the child to make the best use of residual abilities
and achieve maximum satisfaction and enrichment in life.

 Physical therapy. Methods must be suited to the needs of each child, as well as the general
needs arising from the condition; these methods are based on principles of conditioning,
relaxation, use of residual patterns, stimulation of contraction, and relaxation of antagonistic
muscles.
 Orthopedic management. Braces are used as supportive and control measures to facilitate
muscle training, to reinforce weak or paralyzed muscles, or to counteract the pull of
antagonistic muscles; orthopedic surgery sometimes is used to improve function and to
correct deformities, such as the release of contractures and the lengthening of tight heel
cords.
 Technological aids. Devices range from simple items, such as wheelchairs and specially
constructed toilet seats, to completely electronic cottages furnished with a computer, a tape
recorder, a calculator, and other equipment that facilitates independence and useful study
or work; feeding aids such as spoons with enlarged handles for easy grasping or with bent
handles that allow the spoon to be brought easily to the mouth.

Pharmacologic Management
Numerous medications, including the following, may relieve the movement difficulties associated
with cerebral palsy:

 Botulinum toxin with or without casting. Botulinum toxin (Botox) type A may reduce
spasticity for 3-6 months and should be considered for children with cerebral palsy with
spasticity.
 Phenol intramuscular neurolysis. This agent can be used for some large muscles or when
several muscles are treated, but phenol therapy is permanent.
 Antiparkinsonian, anticonvulsant, antidopaminergic, and antidepressant agents. Although
antiparkinsonian drugs (eg, anticholinergic and dopaminergic drugs) and antispasticity
agents (eg, baclofen) have primarily been used in the management of
dystonia, anticonvulsants, antidopaminergic drugs, and antidepressants have also been
tried.

 NURSING RESPONSIBILITIES
1. Ensure therapeutic communication. To ease the change of environment, the nurse needs to
communicate with the family to learn as much as possible about the child’s activities at
home.
2. Enhance self-esteem. Assist the patient to increase his/her personal judgment of self-worth.
3. Provide emotional support. Provide of reassurance, acceptance, and encouragement during
times of stress.
4. Strengthen family support. Utilize the family’s strengths to influence patient’s health in a
positive direction.
5. Prevent injury. Prevent physical injury by providing the child with a safe environment,
appropriate toys, and protective gear (helmet, kneepads) if needed.
6. Prevent deformity. Prevent physical deformity by ensuring the correct use of prescribed
braces and other devices and by performing ROM exercises.
7. Encourage mobility. Promote mobility by encouraging the child to perform age-and
condition-appropriate motor activities.
8. Increase oral fluid intake. Promote adequate fluid and nutritional intake.
9. Manage sleep and rest periods. Foster relaxation and general health by providing rest
periods.
10. Enhance self-care. Encourage self-care by urging the child to participate in activities of daily
living (ADLs) (e.g. using utensils and implements that are appropriate for the child’s age and
condition).
11. Facilitate communication. Talk to the child deliberately and slowly, using pictures to
reinforce speech when needed; encourage early speech therapy to prevent poor or
maladaptive communication habits; and provide means of articulate speech such as sign
language or a picture board.

12. Enforce therapeutic measures. Assist in multidisciplinary therapeutic measures designed to

establish locomotion, communication, and self-help, gain optimal appearance and
integration of motor functions.

REFERENCES:

Retrieved from www.nurseslab/cerebral-palsy, retrieved on February 1, 2020