NCM 234

CARE OF MOTHER AND

CHILD AT RISK OR WITH
PROBLEMS (ACUTE AND
CHRONIC)
• Gestational diabetes GESTATIONAL DIABETES
is abnormal
carbohydrate, fat,
and protein
metabolism that is
first diagnosed during
pregnancy, regardless
of the severity.
2. Gestational diabetes Gestational diabetes is
characterized by further classified as:
abnormal glucose
tolerance test and 1. Gestational diabetes
elevated fasting characterized by an abnormal
glucose. This type of glucose tolerance test (GTT)
gestational diabetes without other symptoms.
must be controlled by Fasting glucose is normal and
insulin (A2). the diabetes is controlled by
diet (A1).
 GESTATIONAL DIABETES
ASSESSMENT FINDINGS:
Risk factors for gestational diabetes include:
• Obesity
• Age over 25 years
• History of large babies (10 lbs. or more)
• History of unexplained fetal or perinatal loss
• History of congenital anomalies in previous pregnancies
• History of polycystic ovary syndrome
• Family history of diabetes (one close relative or two distant ones)
• Member of a population with a high risk for diabetes
(Native American, Hispanic, Asian)
 PATHOPHYSIOLOGY:
• The pancreatic beta
cell functions are
impaired in response
to the increased ➢In gestational diabetes mellitus
pancreatic (type III, GDM), insulin antagonism
stimulation and by placental hormones, human
placental lactogen, progesterone,
induced insulin cortisol, and prolactin leads to
resistance. increased blood glucose levels. The
effect of these hormones peaks at
about 26 weeks’ gestation. This is
called the diabetogenic effect of
pregnancy.
• Fasting blood sugar test
GESTATIONL DIABETES:
• A 50-g glucose screen
• A 3- hour oral glucose
tolerance test DIAGNOSTIC TEST FINDINGS
• The glycosylated (MOTHER)
hemoglobin (HbA 1c)
test (measures glycemic
control in the 4 to 8
weeks before the test is
performed
• Maternal serum alpha- GESTATIONAL
fetoprotein level DIABETES:
• Ultrasonography
• Nonstress test (as early DIAGNOSTIC TEST FINDINGS
as 30 weeks), (FETUS)
contraction stress test,
and biophysical profile
• Lung maturity studies
(by amniocentesis)
• Assess the client’s
understanding of GDM and its
GESTATIONAL
implications for daily life.
• As needed, explain the effects
DIABETES:
of gestational diabetes on the
mother and fetus.
• Point out the need for NURSING MANAGEMENT:
frequent laboratory testing 1. Establish an initial database, and
and follow-up for mother and maintain serial documentation of test
fetus, for example, to prevent results throughout the pregnancy.
infection and assess other
potential complications. 2. Provide client and family teaching.
• Discuss and demonstrate
insulin self-injection
 GDM

Normal Glucose
Tolerance Test
Values:
• Demonstrate how to GDM
self-monitor blood
glucose level. Explain
that blood is generally NURSING MANAGEMENT
tested daily before meals
▪ Assess patient’s level of
and at bedtime. understanding on blood glucose level
• Explain the need to test self-monitoring.
urine for ketones, which ▪ Ensure compliance on regular testing.
are harmful to the fetus. ▪ Document results.
• Point out the
importance of keeping GDM
daily records of blood
glucose values, insulin
dose, dietary intake, NURSING MANAGEMENT
periods of exercise,
periods of
hypoglycemia, kind and
amount of treatment,
and daily urine test
results.
• Explain the need for
continued evaluation GDM
during the postpartum
period until blood
glucose levels are NURSING MANAGEMENT
within normal limits.
• Arrange for the client to
consult with a dietitian
to discuss the
prescribed diabetic diet
and to ensure adequate
caloric intake
• Address emotional and GDM
psychosocial needs.
Intervene appropriately
to allay anxiety NURSING MANAGEMENT
regarding diabetes and
childbirth.
• Prepare the client for
intensive frequent
intrapartum assessment.
• Identify and make GDM
referral to support
groups and resources
available to the client NURSING MANAGEMENT
and family.
• GDM

NURSING
MANAGEMENT:
Client & Family
Teaching
 GDM
• PLEASE WATCH THE
VIDEO: LINK TO WATCH: GDM
https://www.youtube.com/wa
tch?v=N3jnRuzseoM
 HUMAN IMMUNODEFICIENCY VIRUS/
OBJECTIVES: ACQUIRED IMMUNODEFICIENCY SYNDROME

• To discuss the principles of

HIV transmission and
prevention in pregnancy

18
 What Is HIV/AIDS?
• Acquired immunodeficiency
syndrome (AIDS) is caused by
the human immunodeficiency
virus (HIV).

• HIV attacks and destroys white

blood cells, causing a defect in
the body’s immune system.

19
 What Is HIV/AIDS?
• The immune system of an HIV-infected
person becomes so weakened that it
cannot protect itself from serious
infections. When this happens, the
person clinically has AIDS.

• AIDS may manifest as early as 2 years

or as late as 10 years after infection
with HIV.

20
 HIV Transmission Through Sexual Contact
Of every 100 HIV infected adults, 75-85
have been infected through unprotected
intercourse
70% of these infections are from
heterosexual intercourse

STDs, especially ulcerative lesions in

genitalia, increase risk of transmission

21
 Modes of HIV Transmission
- Sexual intercourse
- Accidental exposure to blood/blood
products (e.g., blood transfusions,
shared needles, contaminated
instruments)
- Mother to child during:
pregnancy
birth
breastfeeding
22
 HIV and Contraception
Contraception with protection
Male condom (latex and vinyl)
Female condom
Nonoxynol-9 (antiviral spermicidal cream)1
Diaphragm1
Methods appropriate for use by women with HIV.
They should use a condom for their partner’s protection.

23
 Effect of AIDS on Pregnancy
Infertility
Repeated abortions
Prematurity
Intrauterine growth retardation
Stillbirths
Congenital abnormalities
Embryopathy

24
 HIV Transmission from Mother to Infant
Antenatal
In utero by transplacental passage

Intranatal
Exposure to maternal blood and vaginal secretions
during labor and delivery

Postnatal
Postpartum through breastfeeding

25
 HIV Transmission from Mother to Infant
25-35% of all infants born to HIV-infected
women in developing countries become
infected

90% of HIV-infected infants and children were

infected by mother

26
 HIV Transmission from Mother to Infant
Approximately 600,000 HIV-infected infants are born
every year–at least 1,600 every day–in resource-
constrained countries.

Transmission occurs during pregnancy, labor and

delivery, and breastfeeding.

The rate of mother to child transmission has been reduced

to less than 5 percent among the limited number of HIV-
infected women in developed countries.

27
 HIV Transmission from Mother to Infant
High rates are largely due to the lack of
access to:
-HIV voluntary counseling and testing
- replacement feeding
-selective caesarean section

-antiretroviral drug therapy

28
 HIV Transmission
HIV cannot be transmitted by:
-Casual person to person contact at
home or work or in social or public
places
-Food, air, water
-Insect/mosquito bites
-Coughing, sneezing, spitting
-Shaking hands, touching, dry kissing or
hugging
-Swimming pools, toilets, etc.
29
 AIDS and Infants
Symptoms generally develop by 6 months of
age
Diarrhea
Failure to thrive
Most of these children die before their second
birthday
Children born to HIV-infected parents are likely
to become orphans

30
 Reducing pediatric HIV infection and disease involves three stages:

--preventing HIV infection among women

of childbearing age
--preventing unwanted pregnancy among
HIV-positive women
--preventing mother to child transmission
during pregnancy, labor and delivery, and
breastfeeding

31
 BENEFITS TO HIV TESTING
--EARLY COUNSELING AND
TREATMENT OF HIV INFECTION
--ABILITY TO MAKE DECISIONS
REGARDING PREGNANCY
--IMPLEMENTATION OF
STRATEGIES TO ATTEMPT TO
PREVENT TRANSMISSION TO
FETUS

32
 Protecting Health Care Workers During Labor and Delivery

Precautions during labor:

Protection from blood and amniotic fluids
Protection from sharp instruments
Resuscitation of baby:
No mouth to mouth suction
No mouth to mouth breathing
Precautions following labor:
Proper disinfection of instruments
Proper disposal of placenta and other items

33
 MODE OF DELIVERY - VAGINAL

=ARTIFICIAL RUPTURE OF
MEMBRANES SHOULD BE AVOIDED
= RUPTURE OF MEMBRANES PAST 4
HOURS SHOULD BE AVOIDED
=FETAL SCALP SAMPLING AND THE
USE OF SCALP ELECTRODES
SHOULD BE AVOIDED

34
 MODE OF DELIVERY – CAESAREAN SECTION

HIV INFECTED WOMEN SHOULD BE COUNSELLED

ABOUT ELECTIVE C-S
VERTICAL TRANSMISSION IS REDUCED TO 2% WITH
PACTG 076 THERAPY AND ELECTIVE C-S
TO AVOID SROM & ONSET OF LABOUR, ELECTIVE C-
S IS PERFORMED AT 38 WEEKS
AFTER SROM OR ONSET OF LABOUR C-S IS LESS
PROTECTIVE
TO AVOID C-S MORBIDITY, ANTIBIOTIC
PROPHYLAXIS SHOULD BE CONSIDERED
*SROM (spontaneous release of membranes)

35
 PLEASE WATCH THE VIDEO

https://www.youtube.com/w
atch?v=oyjNYsaFIjc

36
➢- Is a disorder in IRON DEFICIENCY ANEMIA
which hemoglobin
synthesis is deficient
and the body’s
capacity to transport
oxygen is impaired.
Iron deficiency
anemia during
pregnancy is
associated with low
fetal birth weight and
preterm birth
➢During pregnancy,
maternal iron stores are
used for fetal RBC IRON DEFICIENCY ANEMIA
production, thus
causing an iron
deficiency in the mother • PATHOPHYSIOLOGY
➢Many women enter
pregnancy with a deficit
of iron stores, resulting
from a diet low in iron
(inadequate intake),
heavy menses (blood
loss), or unwise weight-
reducing programs
➢Iron stores also tend to be
low in women experiencing
a short period (under 2 yrs.) IRON DEFICIENCY ANEMIA
between pregnancies
➢Iron malabsorption
➢Iron deficiency anemia is
considered a microcytic, • PATHOPHYSIOLOGY
hypochromic anemia,
meaning that inadequate
iron intake results in smaller
RBCs that contain less
hemoglobin. Cells that aren’t
as large and rich in
hemoglobin as they should
be affect the proper
transport of oxygen
➢Fatigue, listlessness, IRON DEFICIENCY ANEMIA
pallor, and exercise
intolerance

➢Some women ▪ ASSESSMENT FINDINGS:

develop pica in
response to the
body’s need for
increase nutrients
➢If anemia is severe or
prolonged, other signs and IRON DEFICIENCY ANEMIA
symptoms may include:
• Dyspnea on exertion
• Inability to concentrate
• Susceptibility to infection ▪ ASSESSMENT FINDINGS:
• Tachycardia
• Coarsely ridged, spoon-
shaped, brittle, thin nails
• Sore, red burning tongue
• Sore, dry skin in the
corners of the mouth
➢Low hemoglobin (less than 10g/dl)
➢Low hematocrit (less then 33%)
➢Low serum iron (less than IRON DEFICIENCY ANEMIA
30microgram/dl)
➢Low serum ferritin (less than
100mg/dl) • DIAGNOSTIC TEST FINDINGS:
➢Low RBC count with microcytic and
hypochromic cells
➢Decreased mean corpuscular
hemoglobin (less than 30g/dl) in
severe anemia
➢Depleted or absent iron stores and
hyperplasia of normal precursor cells
➢Preventing iron deficiency
anemia with prescription
prenatal vitamins is the IRON DEFICIENCY ANEMIA
primary goal

• MEDICAL MANAGEMENT:
➢However, if iron deficiency
anemia does develop, an
iron supplement, such as
ferrous sulfate and ferrous
gluconate, is prescribed.
➢Patients should be advised IRON DEFICIENCY ANEMIA
to eat a well-balanced diet
that includes food high in
vitamins and iron
• MEDICAL MANAGEMENT:

➢If the woman’s anemia is

severe or she can’t comply
with the prescribed oral
therapy, parenteral iron may
be prescribed.
➢Instruct the patient to
use prenatal vitamins
as prescribed IRON DEFICIENCY ANEMIA
➢Administer oral iron
supplement with an
acid, for example, • NURSING MANAGEMENT:
orange juice or a
vitamin C supplement
to enhance absorption
➢Monitor the patient’s
CBC and serum iron
and ferritin levels
regularly
➢Assess the family’s dietary
habits for iron intake, noting IRON DEFICIENCY ANEMIA
the influence of childhood
eating patterns, cultural
food preferences, and family
income on adequate • NURSING MANAGEMENT:
nutrition
➢Monitor the woman’s vital
signs, especially heart rate,
noting any tachycardia
➢Evaluate for signs and
symptoms of decreased
perfusion to vital organs and
symptoms of neuropathy
➢Assess FHR at each visit;
if the patient is
hospitalized, monitor IRON DEFICIENCY ANEMIA
FHR at least every 4
hours
• NURSING MANAGEMENT:
➢Provide frequent rest
periods to decrease
physical exhaustion
➢If the anemia is severe,
expect to administer
oxygen, as ordered, to
help prevent and reduce
hypoxia
 IRON DEFICIENCY ANEMIA
➢Administer iron
supplements as • NURSING MANAGEMENT:
ordered. Use the Z-
track method when
administering iron IM
to prevent skin
discoloration, scarring
and irritating iron
deposits in the skin
➢If the patient receives
iron IV, monitor the IRON DEFICIENCY ANEMIA
infusion rate carefully.
Stop the infusion and
begin supportive • NURSING MANAGEMENT:
treatment immediately
if the patient shows
signs of an allergic
reaction. Also, watch
for dizziness and
headache and for
thrombophlebitis
around the IV site
 IRON DEFICIENCY ANEMIA
➢Offer suggestions for high-
fiber foods to prevent • NURSING MANAGEMENT:
possible constipation from
iron therapy; also warn the
patient that the medication
may cause stools to appear
black and tarry
 NCM 234

CARE OF MOTHER AND

CHILD AT RISK OR WITH
PROBLEMS (ACUTE AND
CHRONIC)
➢Folic acid, or folacin is a FOLIC ACID DEFICIENCY
water-soluble B-9 vitamin ANEMIA
that’s necessary for RBC
formation. Folic acid plays
a major role in preventing
neural tube defects in the
fetus
➢-A common, slowly
progressive megaloblastic
anemia (enlarged RBCs)
➢- Folic acid is found in FOLIC ACID DEFICIENCY
most body tissues where
it acts as a coenzyme in ANEMIA
metabolic processes, • PATHOPHYSIOLOGY
although its body stores
are comparatively small,
this vitamin is plentiful in
most well-balanced
diets. However, folic acid
is water soluble and heat
labile, and is easily
destroyed by cooking
 FOLIC ACID DEFICIENCY
➢About 20% of folic ANEMIA
acid intake is
excreted unabsorbed
➢An insufficient
intake, usually less
then 50mcg/day
generally results in
folic acid deficiency
anemia within 4
months
➢During pregnancy, FOLIC ACID DEFICIENCY
folic acid deficiency
anemia usually occurs
ANEMIA
in women with
multiple gestations,
believed to be the
result of increased
demand of folic acid
by the fetuses
➢Certain drugs, such as FOLIC ACID DEFICIENCY
hydantoin (an ANEMIA
anticonvulsant that
interferes with folate
absorption) and
hormonal
contraceptives may also
play a causative role
➢- Folic acid deficiency
FOLIC ACID DEFICIENCY
may result in megaloblastic
anemia (development of
ANEMIA
large but ineffective RBCs).
If evidence of folic acid
deficiency is present at the
time of birth, the neonate
may be affected as well.
Low levels of folic acid in
pregnant women have been
associated with premature
separation of the placenta,
spontaneous abortions, and
neural tube defects.
-Severe, progressive fatigue FOLIC ACID DEFICIENCY
-Pallor ANEMIA
-Shortness of breath
-Palpitations • ASSESSMENT FINDINGS:
-Diarrhea
- Nausea or anorexia
- Headache, weakness or
light-headedness
- Forgetfulness
- Irritability
- Macrocytic RBCs FOLIC ACID DEFICIENCY
- Decreased ANEMIA
reticulocyte count
- Increased mean • DIAGNOSTIC TEST FINDINGS:
corpuscular volume
- Abnormal platelet
count
- Decreased serum
folate levels (below
4mg/ml)
FATIGUE RELATED TO FOLIC ACID DEFICIENCY
DECREASED HEMOGLOBIN ANEMIA
AND DIMINISHED OXYGEN-
CARRYING CAPACITY OF THE
BLOOD • NURSING DIAGNOSIS:

ALTERED NUTRITION: LESS

THAN BODY REQUIREMENT
RT INADEQUATE INTAKE OF
ESSENTIAL NUTRIENTS
 FOLIC ACID DEFICIENCY
ANEMIA
➢ALTERED TISSUE
PERFUSION RT • NURSING DIAGNOSIS:
INSUFFICIENT
HEMOGLOBIN AND
HEMATOCRIT
 FOLIC ACID DEFICIENCY
➢- Folic acid
supplementation, ANEMIA
orally (1-5 mg/day)
or parenterally (to ▪ MANAGEMENT :
patients who are
severely ill, have
malabsorption or
can’t take oral
meds)
➢- Diet high in
folic acid
➢- Strongly urge FOLIC ACID DEFICIENCY
women expecting to ANEMIA
become pregnant to
begin a vitamin
supplement (over- • NURSING MANAGEMENT:
the-counter) or be
conscious about
eating folic acid rich
foods such as fruits
and green leafy
vegetables, wheat
products, peanut
butter, and liver
- Assist with planning a FOLIC ACID DEFICIENCY
well-balanced diet, ANEMIA
including foods high in
folic acid and between-
meal snacks • NURSING MANAGEMENT:
- Encourage the woman
to eat rich source of
vitamin C at each meal
to enhance absorption
of folic acid
- Administer folic acid
supplement as ordered
- If the patient has FOLIC ACID DEFICIENCY
severe anemia and ANEMIA
requires hospitalization,
plan activities, rest
periods, and diagnostic • NURSING MANAGEMENT:
tests to conserve energy
= Monitor pulse
rate often
= If tachycardia
occurs, the patient’s
activities are too
strenuous
- Monitor the patient’s CBC,
platelet count, and serum
folate levels as ordered
- Assess maternal vital signs
and FHR as indicated
FOLIC ACID DEFICIENCY
ANEMIA
• NURSING MANAGEMENT:

- Instruct the woman in the

use of prescribed folic acid
supplement and need to
continue supplement
throughout pregnancy
- Early spontaneous FOLIC ACID DEFICIENCY
abortion ANEMIA

- Premature separation COMPLICATIONS:

of the placenta

- Fetal neural tube

defects
PLEASE WATCH THE
VIDEO: ANEMIAS IN PREGNANCY
https://www.youtube
.com/watch?v=e4baN
HUxP8I
➢Refers to the misuse or SUBSTANCE ABUSE
overuse of substances,
including alcohol,
prescription, OTC, and
illicit drugs

➢During pregnancy, most

commonly associated
with alcohol and illicit
drugs
➢Substance abuse leads to
SUBSTANCE ABUSE
fetal harm

• PATHOPHYSIOLOGY
➢Substance abuse is most
detrimental when used
during the first trimester
when fetal organs are
being formed
SUBSTANCE ABUSE

• ASSESSMENT FINDINGS
 SUBSTANCE ABUSE
➢Therapy depends on
the substance being
abuse • MANAGEMENT

➢Long-term
counseling and
rehabilitation is
necessary
➢Provide the patient with SUBSTANCE ABUSE
support and guidance
➢Assist with measures to • NURSING MANAGEMENT
obtain necessary support
services, such as adequate
nutrition and housing
➢Encourage participation in
an active treatment
program
➢Monitor the woman as
closely as possible SUBSTANCE ABUSE
during the pregnancy
for adequate
progression, fetal
growth and • NURSING MANAGEMENT
development, and signs
and symptoms of
complications

➢Enlist the aid of social

services and other
supportive agencies as
necessary
➢Prepare for the delivery of
a substance dependent SUBSTANCE ABUSE
neonate; anticipate drug
screening on the
neonate’s urine and stools • NURSING MANAGEMENT

➢Anticipate the possible

placement of the neonate
in foster care if the
mother is unable to
adequately care for the
neonate
➢Smoking, drinking
SUBSTANCE ABUSE
alcohol, and using drugs
while pregnant can
harm the growing fetus
➢Women who smoke
cigarettes have a higher
risks for miscarriages,
stillbirth, premature or
low birth weight
• When the baby is SUBSTANCE ABUSE
born more likely to
get asthma or
chronic ear infection
• The babies can be
more irritable, grow
slowly, and have
behavioral problems.