Module 1: Framework of Maternal and Child Health Nursing

Maternal Mortality rate in 2009

160:100,000 live birth

Maternal Mortality rate in 2013

120:100,000 live birth

leading causes of maternal death

1. related to labor, delivery, and puerperium

2. hypertension

3. postpartum hemorrhage

4. pregnancy with abortive outcomes

Related to labor, delivery, and puerperium (Number, Percent)

Number: 660

Percent: 38.4%

Hypertension (Number, Percent)

Number: 605

Percent: 35.2%

Postpartum hemorrhage (Number. Percent)

Number: 298

Percent: 17.3%

Pregnancy with abortive outcomes (Number, Percent)

Number: 158

Percent: 9.1%

Factors affecting maternal deaths

1. frequency and spacing of birth

2. maternal undernutrition

3. maternal age and stature

4. appropriate medical & midwife support

5. access to emergency and intensive treatment

6. lack of management capacity in health system

7. insufficient care during pregnancy and delivery

8. HIV infection

causes of infant death

1. Pneumonia (3146: 14.3%)

2. Bacterial sepsis (2731: 12.4%)

3. Respiratory distress (2347: 10.7%)

3 delays that lead to maternal and neonatal death

1. delay in identification of complication

2. delay in referral

3. delay in management complications

delay in identification of complication

• failure to recognize signs

• lack of money

• no person to take care of children at home

• unplanned/unwanted pregnancy

• lack of companion going to health facility

• fear of being ill-treated in health facility

Delay in Referral

• distance from home to healthcare facility

• lack of conditional road

• lack of emergency transportation

• lack of awareness

• lack of community support

Delay in management complications

• lack of healthcare providers

• shortage supplies

• lack of equipment

• lack of competence

• weak referral system

50%

percentage of birth that takes place at home

25%

percentage of birth being attended by hilots

DOH essential package of child survival interventions

1. Skilled attendance during pregnancy, childbirth, and immediate postpartum

2. care of the newborn

3. breastfeeding and complimentary feeding

4. micronutrient supplementation

5. immunization of children and mothers

6. integrated management of sick children

7. injury prevention and control

8. birth spacing

DOH programs / Intervention for child care

1. Early Essential Newborn Care

2. Infant and young children feeding

3. Newborn screening

4. Integrated management of childhood illness

5. immunization programs

Danger signs in pregnancy

1. high fever

2. severe vomiting

3. severe headache

4. pallor and laboured breathing

5. swelling of hands and feet

6. foul vaginal discharge

7. severe abdominal pain

8. premature rupture of membrane (PROM)

9. rhythmic cramping

10. burning sensation with urination

11. blurry vision

12. high BP

Pre-natal Risk: Pre-existing risk

1. age

2. parity

3. social factors

4. environmental factors

5. marital status

6. pre-existing disease

7. physical stature

8. nutritional status

Pre-natal Risk: Risk emerging during pregnancy

1. anemia

2. hemorrhage

3. hypertension

4. transverse lie

5. malposition

6. suspected COPD

7. negative attitude to pregnancy

Pre-natal Risk: Risk of labor/delivery

1. premature rupture of membrane

2. amnionitis

3. transverse lie

4. prolonged/obstructed labor

5. intra-partal bleeding from previa/abruptio

Pre-natal Risk: Risk of postpartum

1. Puerperal infection

2. hemorrhage

3. sub-involution

4. post operative complication

5. thrombophlebitis

6. depression

causes of congenital disorder in the Philippines

1. Dominant single-gene disorder (7)

2. recessive singe gene disorder (2.3)

3. X-linked recessive single gene (1.3)

4. Chromosomal disorders (4.2)

5. malformations (62.9)

Genetics

study of heredity and variations of inherited characteristics

cytogenetics

study of chromosomes by light microscopy

Genes

• are basic units of heredity that determine both the physical and cognitive characteristics of people

• composed of segments of DNA, they are woven into strands in the nucleus

Chromosomes

• threadlike structures of nucleic acids and protein found in the nucleus of most living cells

• 46 pairs in each human (22 pair of autosomes, and 1 pair of sex characteristics)

XX chromosomes

• female chromosomes

• large symmetric

XY chromosomes

• male chromosomes

• smaller type

phenotype

outward appearance or expression of genes

genotype

• his/her actual gene composition

• impossible to predict

genome

• complete set of genes present

Gregor Mendel

known for his work in principle of genetic inheritance of disease are same as those that govern genetic inheritance of physical characteristics

Homozygous trait

are 2 like chromosomes

Heterozygous trait

gene difference

Dominant genes

always expressed preferences to recessive genes

Autosomal Dominant Inheritance

either a person has two unhealthy genes or is heterozygous, with the gene causing stronger than the corresponding healthy recessive gene from the same trait

e.i.

Huntington disease - neurological disorder, loss of motor control & intellectual deterioration

Autosomal Recessive Inheritance

disease does not occur unless two genes for the disease are present

e.i.

cystic fibrosis, albinism, Tay Sachs disease, galactosemia, phenylketonuria, Rh incompatibility

X-linked Dominant inheritance

genes are only transmitted by the female sex hormones ( X chromosomes) only one chromosome needs to be present for the symptoms of disorder to be manifested

e.i.

Alport syndrome - progressive kidney failure disorder

X-linked Recessive Inheritance

Inheritance of the disorder is applicable to the recessive gene (heterozygous) males with recessive gene will affect female children. only males can show manifestation of the disease.

Multifactorial (polygemic) Inheritance

appear to occur from multiple gene combinations possibly combined with environmental factors

more than single gene/ human lymphocyte antigen is involved

e.i.

• heart disease

• diabetes

• pyloric stenosis

• cleft lip/palate

chromosomal abnormalities (Cytogenic disorder)

• fault in the number or structure of chromosomes which result to missing/distorted genes

Karyotype

photographed and displayed arrangement of chromosomes

nondisjunction abnormalities

chromosomal abnormalities occur in the division is uneven, result can show that spermatozoon has 24 chromosomes while ovum has 22 chromosomes or vice versa

meiosis

cell division in which number of chromosomes in the cell is reduced to haploid number for reproduction (instead of 46 chromosomes there would be 23 chromosomes)

Down Syndrome (47XY21- or 47XX21-)

• occurs in 1/800 pregnancies who are older than 35 yrs of age

• characteristics: broad and flat nose, enlarge tongue, simian line, IQ 50-70 or less than 20

• management: early educational & play programs, proper hygiene for infection reduction, slow feeding, physical examination at birth

Patau syndrome/ trisomy 13 syndrome (47XY13+ or 47XX13+)

• child has an extra chromosome 13 and is severely cognitively challenged

• happens 0.45/1000 births

• most children do not survive beyond infancy

• characteristics: cleft lip/palate, heart disorder, abnormal genitalia, microcephaly, supernumerary digits

Edwards syndrome/ Trisomy 18 syndrome (47XX18+ or 47XY18+)

• have 3 copies of chromosome 18

• happens 0.23/1000 live births

• most children do not survive beyond infancy

• characteristics: cognitively challenged, runt, small jaw, mishappen fingers and toes, rocker bottom feet.

Klinefelter syndrome (47XXY)

• Males with extra X chromosomes

• happens 1/1000 birth. not noticeable at birth

• characteristics: small tests, ineffective sperm, gynecomastia, risk for male breast cancer

Turner Syndrome (45X0)

• has only one functional X chromosomes

• 1/10000 live births. can be identified during pregnancy due to excess skin on the side of the neck

• Characteristics: gonodal dysgenesis, one functional ovaries ,SSH does not appear on puberty, stricture of aorta, hairline on nape is low set. webbed and short necked, Congenital heart failure

• Management: human growth hormone, estrogen at 13, surrogate/oocyte transfer

Deletion abnormalities

chromosome disorder where chromosomes break during cell division, causing normal number of chromosomes plus or minus an extra portion of a chromosome (45.75 or 47.5 chromosome)

cri-du-chat syndrome (46XY5P-)

• one portion of chromosome 5 is missing

• characteristics: abnormal cry, small head, wide-sets of eye, palpebral fissure of the eyes, recessed mandible

Fragile X syndrome (46XY23Q-)

• most common cause of cognitively challenged males

• X-linked disorder wherein long arm of X is defective results to inadequate proton synaptic responses

• happen 1/4000 males

• carrier females can showcase physical & cognitive characteristics

• Characteristics: autism, hyperactivity, reduced intellectual functioning, large head, long face, high forehead, prominent lower jaw, large protruding ear, obesity

• management: stimulants, atypical antipsychotics, serotonin reuptake inhibitors

Translocation abnormalities

• additional chromosomes through another route

• correct number of chromosomes is present but one chromosome can have a misplaced connection causing the addition of chromosome leading to feature of down syndrome

balanced translocation carrier

parents appearance and functioning are normal because total chromosome count is 46 chromosomes

unbalanced translocation carrier

a parent that has more/less chromosome carried in a sperm or ovum

mosaicism

• abnormal condition that occurs after fertilization of the ovum. different cells in the body has different chromosome count. children with DS w normal intelligence have this type of pattern

• cause: teratogenic condition, x-ray or drug exposure, disturbing normal cell division

• DS with _______ chromosome represent 46XX | 47XX21- (showing some cells have 46 chromosomes while some has 47 chromosomes)

Isochromosomes

• chromosomes divide problem. chromosomes divides horizontally not vertically causing mismatched long & short arms and an extra chromosome exists

• Turner syndrome occur because of this phenomena

consanguineous couple

couple that is related

dermatoglyphics

study of surface markings of the skins

Preimplantation diagnosis

timing: day 3-5 of embryo

process: cell sample obtained from day 3 or day 5 embryo prior to implantation in mother during vitro fertilization process

Risk : invasive to embryo, risk of destruction of embryo

Result: only 9-11 of chromosomes can be evaluated from the sample

Nuchal Translucency

timing: 11-14 weeks

process: ultrasound to assess thickness at fetus neck maternal blood draw

Risk : noninvasive ultrasound and maternal blood draw

Result: screening test for down syndrome trisomy 18 & 13

cfDNA

timing: 11+ weeks can be done as early as 7 weeks

process: maternal blood draw, fetal cell fragments in maternal blood are assessed

Risk : noninvasive maternal blood draw

Result: Screening test for abnormal amounts of chromosomes and microdeletions in fetal DNA

Chorionic villa sampling

timing: 10-12 weeks

process: biopsy of placenta

Risk : invasive risk of miscarriage

Result: diagnostic test for karyotype

Maternal quadruple marker screen

timing: 15-20 weeks

process: maternal blood draw

Risk : noninvasive, maternal blood draw

Result: screening test for down syndrome, trisomy 18 and 13

Amniocentesis

timing: 15-18 weeks

process: collection of amniotic fluid containing fetal skin cells through maternal abdomen

Risk : invasive risk of miscarriage

Result: diagnostic test for karyotype, shows common chromosomal disorders that can be diagnosed through _______

Percutaneous umbilical blood sampling

timing: >17 weeks

process: fetal umbilical blood sampling through maternal abdomen

Risk : invasive risk of miscarriage

Result: diagnostic test for karyotype and fetal blood diseases

fetal anatomy ultrasound

timing: 18-22 weeks. ideal timing

process: ultrasound of the fetal anatomy

Risk : noninvasive - ultrasound

Result: screening test for visual fetal anomalies

fetoscopy

timing: second and third trimesters

process: small camera and instrument passed into the amniotic sac to view and treat anomalies

Risk : invasive risk of miscarriage

Result: Often used to treat disorders like twin-to-twin transfusion

Newborn Screening

timing: Day 2-several weeks after birth

process: a blood sample via heel prick or blood draw from newborn

Risk : noninvasive

Result: screening for genetic disorders via serum DNA or other factors