COURSE NUMBER: NCM 109

COURSE TITLE: CARE OF MOTHER, CHILD, FAMILY AND POPULATION GROUP AT-RISK OR WITH PROBLEMS
WEEK 1 and 2

COURSE LEARNING
OUTCOME
➢ Integrate concepts, theories and principles of sciences and humanities in the formulation and application of
appropriate care during childbearing and childrearing years.
➢ Apply appropriate nursing concepts and actions to at-risk/ high risk/ sick clients during childbearing and
childrearing years holistically and comprehensively.
➢ Assess the at-risk mother and child with the use of specific method and tools to address existing health needs.
➢ Formulate with the client a plan of care to address needs/ problems of at/high risk mother and child.
➢ Implement safe and quality nursing interventions to address needs/ problems of at-risk mother and child

STUDENT LEARNING
OUTCOME
1. Identify the goals and philosophy of maternal and child health nursing.
2. Define common statistical terms used in the field, such as infant and maternal mortality.
3. Apply concepts of family centered care to maternal and child health nursing
4. Understand the importance of genetics and genetic counselling to further integrate the importance of
childbearing especially with those with disabilities.

LEARNING CONTENT: FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING(MCN)

FOCUSING ON AT-RISK, HIGH RISK, AND SICK CLIENTS
A. INTRODUCTION
Welcome students, for the next two weeks we will learn together about Framework for Maternal and Child
Health Nursing (MCN) focusing on at-Risk, high-Risk, and Sick Clients may you enjoy your journey with me. The
next two weeks topics will be an introduction and preparation for the next main topics about this subject.

This course deals with concepts, principles, theories, and techniques in the nursing care of at risk/ high risk/ sick
client during childbearing years toward health promotion, disease prevention, restoration and maintenance, and
rehabilitation. The learners are expected to promote safe, appropriate and holistic nursing care to clients
utilizing the nursing process.

Topics to be covered for the next two weeks:

A. National Health Situation on MCN
B. Statistics on MCN
C. Genetics and Genetic Counseling

B. LESSON CONTENT

LEARNING POINT: Framework for Maternal and Child Health Nursing

The care of childbearing and childrearing families is a major focus of nursing practice, because to have
healthy adults you must have healthy children. To have healthy children, it is important to promote the health of
the childbearing woman and her family from the time before children are born until they reach adulthood. Both
preconceptual and prenatal care are essential contributions to the health of a woman and fetus and to a family’s
emotional preparation for childbearing and childrearing. As children grow, families need continued health
supervision and support. As children reach maturity and plan for their families, a new cycle begins and new
support becomes necessary. The nurse’s role in all these phases focuses on promoting healthy growth and
development of the child and family in health and in illness. Although the field of nursing typically divides its
concerns for families during childbearing and childrearing into two separate entities, maternity care and child
health care, the full scope of nursing practice in this area is not two separate entities, but one: maternal and
child health nursing

National health situation on MCN

The Philippines' commitment to reducing maternal and early infant morbidity and mortality
and describes a strategy for achieving these goals (Department of Health, 2000). Information about the extent
and types of maternal and child health care actually received in the population can be used to assess progress
toward Safe Motherhood objectives and to plan for the improvement of services to women who need maternity
related care. Information about the health care women receive during pregnancy and after childbirth, and data
on infant health care, are presented in this section of the report.

The Department of Health recommends that all pregnant women have at least four prenatal care visits.
It further recommends that, for early detection of pregnancy-related risks, the first prenatal checkup should
occur in the first trimester of the pregnancy. Prenatal care includes advice to expectant mothers on nutrition
and health care, examination and screening, immunization and micronutrient supplementation. It also involves
educating pregnant women about the symptoms of risk conditions to improve detection and treatment of
pregnancy complications. in the 2002 MCHS, respondents were asked whether they consulted anyone for
prenatal care during the pregnancy preceding each live birth occurring from April 1, 1997 to the date of the
interview. If more than one prenatal care provider was mentioned for a particular pregnancy, the interviewer
was instructed to record all of these care providers. Approximately 6.5 million (or 94.1 percent) of the 6.9 million
women with surviving children below five years of age in 2002 received some prenatal care during pregnancy
with the youngest surviving child. This percentage is slightly lower than that from the 2001 MCHS (94.6 percent).
A higher percentage of rural women (7.3 percentage) had no prenatal visit in 2002 compared with urban women
(4.2 percent). Urban women were more likely to have had more prenatal care visits than rural women.

Goals of MCN are broad b/c the scope of practice or range of practice includes the ff:
1. Preconceptual Health Care
2. Care of women during 3 trimesters of pregnancy
➢ 1st trimester (1st – 3rd month)
➢ 2nd trimester (4th – 6th month)
➢ 3rd trimester (7th – 9th month)
3. Care of women during Puerperium or 4th Trimester (6 weeks after childbirth)
4. Care of infants during Perinatal Period (6 weeks before conception and 6 weeks after birth)
5. Care of children from birth to adolescence
6. Neonatal (28 days of life); Infancy (1 – 12 months); Adolescence (after 18 y/o)
7. Care in settings as varied as the birthing room, the PICU, and the home.

Philosophies of MCN
1. MCN is Family Centered; assessment must include both family and individual assessment.
2. MCN is Community Centered; health of families depends on & influences the health of communities.
3. MCN is Evidence Based because critical knowledge increases
4. MCN includes independent nursing functions because teaching & counselling are major interventions.
6. MCN Nurse, Advocate (protects the rights of family members, including fetus)
7. Health Promotion and Disease Prevention to protect health of new generation.
8. MCN is a challenging role for nurses
Framework for MCN
➢ Nursing Process (ADPIE)
➢ Evidence Based Practice
➢ Nursing Research
➢ Nursing Theory

4 Phases of Health Care

1. Health Promotion
• Educating clients to be aware of good health through teaching and role modelling
Ex. Family planning, teach the importance of safe sex practice, importance of immunizations
2. Health Maintenance
• Intervening to maintain health when risk of illness is present
Ex. Encourage prenatal care, importance of safeguarding homes by childproofing it against poisoning
3. Health Restoration
• Diagnosing and treating illness using interventions that will return client to wellness fast
Ex. Care of child during illness, care of woman during pregnancy complications
4. Health Rehabilitation
• Preventing further complications from an illness
• Bringing client back to an optimal state of wellness
• Helping client accept inevitable death
Ex. Encourage continuous therapies and medications

Trends in Maternal and Child Health Nursing Population

STATISTICS ON MCN

Measuring Maternal and Child Health / Statistical Terms Used to Report Maternal and Child Health

1. Birth Rate – no. of births per 1000 population

2. Fertility Rate – no. of pregnancies per 1000 women of childbearing age
3. Fetal Death Rate –no. of fetal deaths weighing more than 500 g or more per 1000 live births
4. Neonatal Death Rate
Neonatal Period – 1st 28 days of life; Infant is called Neonate
No. of deaths per 1000 live births occurring
5. Perinatal Death Rate
Perinatal Period – 6 weeks before conception and 6 weeks after childbirth
No. of deaths of fetuses weighing > 500g and within the first 28 days of life per 1000 birth.
6. Infant Mortality Rate – no. of deaths per 1000 live births in the first 12 months of life.
7. Childhood Mortality rate – no. of deaths per 1000 population in children; 1 – 14 y/o
8. Maternal Mortality Rate – no. of maternal deaths per 100,000 live births that occur as direct result of
reproductive process.

Trends in Health Care Environment

1. Cost containment –reducing the cost of health by closely monitoring the cost of personnel, use and brands of
supplies, length of hospital stays, no. of procedures carried out, and no. of referrals while maintaining quality
care.
2. Increasing Alternative Settings and Styles for Health Care
• LDRP Rooms (Labor – Delivery – Recovery – Postpartum) a more natural childbirth environment as a
birthing room. Family members are invited to stay to be a part of childbirth.
• Retail Clinics or Emergent Care Clinics located in shopping malls
• Ambulatory Clinics or at home to avoid long hospital stays for women and children
3. Including Family in Health Care
4. Increasing Intensive Care Units
• NICU (Neonatal Intensive Care Unit) or ICN (Intensive Care Nursery)
• PICU (Pediatric Intensive Care Unit)
5. Regionalizing Intensive Care – ex. Premature infant transferred to regional hospital
6. Increasing the Use of Alternative Treatment Modalities – alternative method of therapies such as acupuncture
and therapeutic touch; herbal remedies.
7. Increasing Reliance on Home Care – decreased hospital stays
8. Increasing Use of Technology – use of internet, charting in computer, using Doppler
9. Free birthing – women giving birth without health care provider supervision; unassisted birth
10. LAMAS – breathing techniques

Legal Considerations of MCN Practice

➢ Identifying and Reporting Child Abuse

➢ Child can bring a lawsuit when they reach legal age
➢ Informed Consent for invasive procedure and any risk that may harm the fetus
➢ In divorced or blended families, nurse has the right to give consent.
➢ Note: Nurses are legally responsible to protect the rights of their client and documentation is essential
to protect nurse and justify his or her actions.

Ethical Considerations of Practice

1. Conception Issues
➢ In Vitro Fertilization
➢ Embryo Transfer
➢ Cloning
➢ Stem Cell Research
➢ Surrogate Mothers
2. Abortion
3. Fetal Rights vs Rights of the mother
4. Use of Fetal Tissue for Research
5. Resuscitation
6. No. of procedures or degree of pain that a child should asked to achieve better health
7. Balance between modern technology and quality of life.

GENETICS

Study of how traits are passed from parent to offspring. Traits are determined by the genes on the
chromosomes. A gene is a segment of DNA that determines a trait.

The study of the way animals & plants passes on to their offspring such as:
eye color, hair color, height, body build, blood types, intelligence, gender, etc.

Hereditary is the characteristics that a child receives from both parents.

Chromosomes come in homologous pairs, thus genes come in pairs.

Homologous pairs – matching genes – one from female parent and one from male parent
Example: Humans have 46 chromosomes or 23 pairs. One set from dad – 23 in sperm One set from mom – 23 in
egg.
Dominant and Recessive Genes
Gene that prevents the other gene from “showing” – dominant
Gene that does NOT “show” even though it is present – recessive
Symbol – Dominant gene – upper case letter – T
Recessive gene – lower case letter – t
Genotype and Phenotype
Combination of genes an organism has (actual gene makeup) – genotype
Ex: TT, Tt, tt
Physical appearance resulting from gene make-up – phenotype
Ex: hitchhiker’s thumb or straight thumb
Sex Determination
People – 46 chromosomes or 23 pairs
22 pairs are homologous (look alike) – called autosomes – determine body traits
1 pair is the sex chromosomes – determines sex (male or female)
Females – sex chromosomes are homologous (look alike) – label XX
Males – sex chromosomes are different – label XY

Incomplete dominance and Codominance

When one allele is NOT completely dominant over another (they blend) – incomplete dominance
Example: In carnations the color red (R) is incompletely dominant over white (W). The hybrid color is
pink. Give the genotypic and phenotypic ratio from a cross between 2 pink flowers.

When both alleles are expressed – Codominance

Example: In certain chicken’s black feathers are codominant with white feathers.
Heterozygous chickens have black and white speckled feathers.

Sex – linked Traits

➢ Genes for these traits are located only on the X chromosome (NOT on the Y chromosome)
➢ X linked alleles always show up in males whether dominant or recessive because males have only one X
chromosome
Hemophilia – blood won’t clot

Multiple Alleles
3 or more alleles of the same gene that code for a single trait
In humans, blood type is determined by 3 alleles – A, B, and O
BUT each human can only inherit 2 alleles
1. Dominant – A and B (codominance)
Recessive – O
2. Blood type – A = AA or AO
B = BB or BO
AB = AB
O = OO
Mutations

Mutation – sudden genetic change (change in base pair sequence of DNA)

Can be: Harmful mutations – organism less able to survive: genetic disorders, cancer, death
Beneficial mutations – allows organism to better survive: provides genetic variation
Neutral mutations – neither harmful nor helpful to organism
Mutations can occur in 2 ways: chromosomal mutation or gene/point mutation

Chromosomal mutation:
less common than a gene mutation
more drastic – affects entire chromosome, so affects many genes rather than just one
caused by failure of the homologous chromosomes to separate normally during meiosis
chromosome pairs no longer look the same – too few or too many genes, different shape

Examples:
➢ Down’s syndrome – (Trisomy 21) 47 chromosomes, extra chromosome at pair #21
➢ Turner’s syndrome – only 45 chromosomes, missing a sex chromosome (X) Girls affected – short, slow
growth, heart problems.
➢ Klinefelter’s syndrome – 47 chromosomes, extra X chromosomes (XXY) Boys affected – low
testosterone levels, underdeveloped muscles, sparse facial hair

Gene or Point Mutation most common and least drastic only one gene is altered
Examples: Recessive gene mutations:
➢ Sickle cell anemia – red blood cells are sickle shaped instead of round and cannot carry enough oxygen
to the body tissues – heterozygous condition protects people from malaria.
➢ Cystic fibrosis – mucous builds up in the lungs
➢ Tay-Sachs Disease – deterioration of the nervous system – early death
➢ Phenylketonuria (PKU) – an amino acid common in milk cannot be broken down and as it builds up it
causes mental retardation – newborns are tested for this.

Dominant gene mutations:

➢ Huntington’s disease – gradual deterioration of brain tissue, shows up in middle age and is fatal
➢ Dwarfism – variety of skeletal abnormalities

Detecting Genetic Disorders

picture of an individual’s chromosomes – karyotype
amniotic fluid surrounding the embryo is removed for analysis – amniocentesis

What 4 FACTORS may contribute to Multiple Births?

1. History in the family
2. Increased hormones naturally
More than 1 egg released
3. Fertility Drugs
More than 1 egg released
4. Age 32-36

Likelihood of multiple pregnancies in the United States

Twins: Blacks- 1 in 73 Whites 1 in 93
Triplets: 1 in 10,000
Quadruples: 1 in 620,000

Sex - Linked or X - Linked Defect: When an X-gene from the mother is faulty. There is a 50/50 chance of the
child inheriting the disorder.
Syndrome: When a group of signs and symptoms occur together and characterize a particular problem.
Congenital Malformation: A condition that is present at birth.
Multi-factorial Defects: Interaction of genes with other genes OR with environmental factors.
Chromosomal Error: The fertilized egg cell that contains chromosomes in an abnormal number, structure or
arrangement.

In this case abnormalities of childbearing may vary according to genetics and heredity that is why genetic
counselling may help those pregnant women that are at risk and high risk in having child with abnormalities that
may cause complications to their pregnancy.

GENETIC COUNSELLING

Genetic counselling gives you information about how genetic conditions might affect you or your family.
The genetic counselor or other health care professional will collect your personal and family health history. They
can use this information to determine how likely it is that you or your family member has genetic conditions.
Based on this information, the genetic counselor can help you decide whether a genetic test might be right for
you or your relative.
The preventative, or medical model is the phase of medicalization of GC. Genetics has undergone a
different development from other basic sciences of medicine, which developed within medical schools. Genetics
initially developed among zoologists and botanists and it was they who perceived its relevance to human beings.
As the philosophical basis of medicine widened to include the concept of prevention (preventative medicine)
and with the decline in the number of deaths due to infectious diseases and the relative increase in
constitutional diseases in developed countries, medicine became more and more appropriate for the
development of genetics.
The primary objective of this document was to protect people and families with genetic diseases, with
the intention of assisting or provide guidance to governments and health services in member states to ensure
that genetic information and genetics services are made more widely accessible in medical practice within
acceptable ethical principles. The secondary objective is to allay fears and reassure the public that adequate
controls are in existence to prevent abuses of genetic information and to avoid unacceptable practices,
recognizing that advances in genetics have the potential to significantly improve the health of people when
appropriately applied at the individual, family and community levels. This information must be integrated in an
ethical manner and with respect for religious and cultural diversity.

The current conception of genetic counseling

This process involves an attempt by one or more appropriately trained persons to help the individual or family:
➢ comprehend the medical facts, including the diagnosis, the probable course of the disorder (prognosis),
and the available management (treatment);
➢ appreciate the way heredity contributes to the disorder, and the risk of recurrence in specified relatives;
➢ understand the options for dealing with risk of recurrence, with relation to the family’s reproductive life;
➢ choose the actions which seem appropriate to them in view of their risk and their family goals and act in
accordance with that decision

Clinical situations in children where genetic counseling is necessary

Without doubt, pediatricians are the physicians who will most often come into contact with patients and
families in need of genetic assessment during their professional lives and so they must always be alert to this
need, particularly when presented with:
➢ Cases of stillbirth and neonatal mortality, which should always have their etiology defined in order that
we can determine whether there is a probability of recurrence in the same family. Autopsies should be
requested and pediatricians should work with families to help them to understand the need for this. The
autopsy should be carried out by a team trained to identify the true etiology and prepared to diagnose
genetic diseases, whether dysmorphological or metabolic.
➢ Children with congenital defects, particularly when the child presents with multiple congenital
anomalies.
➢ Children who are severely ill and where there is suspicion of genetic metabolic diseases.
➢ Children with genital ambiguity or abnormal sexual development.
➢ Children with neuropsychomotor delay or mental deficiency of undefined cause or obviously genetic
etiology.
➢ Children with deficient or excessive growth of undefined cause or with suspected genetic disease

All of the families of children diagnosed with genetic diseases must be made aware of the importance of
going through the GC processes. It is very important that the referring physician tries to explain as well as
possible why they are making a referral and the nature of the service that will be offered. The issue of explaining
the etiological mechanisms of genetic diseases, evaluating family members and defining risks of
occurrence/recurrence are of great importance to families with these types of diseases. It is fundamental that
the GC process be based on non-directive counseling carried out by qualified professionals and that it be a
continuous process.

Genetics services need to invest more in GC itself and in follow-up of families. We must balance
technological and scientific questions with humanization of care. It is of fundamental importance to work to
improve the communication process between GC professionals and families, so that the latter may obtain a
better understanding of the situation they are living through and participate actively in all of the decisions they
will have to take during their lives as a result of having genetic abnormalities in their families.

References:

White, Lois, Foundation of Maternal and Pediatric Nursing 2nd Edition

Maternal and Child Health Nursing Care of Childbearing & Childrearing family (9th Edition)
Pilliteri, Adele. Maternal and Child Health Nursing: Care of Childbearing & Childrearing family 5th Edition,
Lippincott Williams and Wilkins 2007.