maternity unit 2: Part 2 (ch 14, 15, 26)

how much folic acid should all women who are capable of becoming pregnant take

• 0.4 mg or 400 mcg daily in addition to folic acid in diet

how much folic acid should all women who have had babies with neural tube defects take

• 4mg daily at least 1 month before attempting to conceive and through the first trimester of pregnancy

How much weight should underweight women gain in pregnancy

• BMI of 18 or less

• 28-40 lbs

How much weight should normal BMI women gain in pregnancy

• BMI of 18.5-24.9

• 25-35 lbs

How much weight should overerweight women gain in pregnancy

• BMI of 25-29.9

• 15-25 lbs

How much weight should obese women gain in pregnancy

• BMI of 30 or more

• 11-20 lbs

how do calorie needs change in pregnancy

• 1st trimester - no change

• 2nd trimester - 340 cal increase

• 3rd trimester - 452 cal increase

Protien needs

71 grams a day (not pregnant 46g/day)

protein demands come From

• rapid growth from fetus

• enlargement of uterus , placenta and mammary glands

• formation of amniotic fluid

• increased maternal blood volume and plasma protein

Fat intake

• no more than 20-35% of moms daily calories

• avoid trans fatty acids

• DHA (in seafood) and AA essential to neurological and eye function of baby

• 8-12oz of seafood per week in enough DHA

fat supplements

• omega 3 reduce risk for preterm birth and improved neurological and visual development

healthy fish

• shrimp, salmon, pollock, catfish, and canned light tuna

• commercially bought fish

bad fish (high in mercury )

• shark, swordfish, king mackerel, and tilefish

• limit intake of fish caught by friends and family

• limit intake of albacore or white tuna and tuna steaks

• can cause neurotoxicity

carbs demand in pregnancy

• 175g/day

• no more than 45-65% of daily caloric intake

• 28g of fiber daily - green leafy vegetables

Vitamin A

• essential for cell differentiation and development of heart, spine eyes and ears

• excessive amounts = teratogen

• supplements are not recommended

Vitamin D

• role in absorption and metabolism of calcium

• deficiency may lead to neonate hypocalcemia

• higher risk in dark skinned mom

Vitmamin K

• prothrombin and clotting factors syntheses

• brocoli, spinach, iceberg lettuce, oils

• baby still needs vitamin K shot after birth

Iron supplementation rules

• take at bedtime if abd pain occurs

• if dose is missed take within 13 hours of that dose, but do not double dose

• keep in childproof container

• can cause black or green stool and constipation (increase fiber!)

what increases iron absorption

• Vitamin C

• heme iron found in meat

• empty stomach

what decreases iron absorption

• bran, tea, coffee, milk, egg yolk, oxalates (spinach and Swiss chard)

• avoid when taking with supplement

Alcohol

• no safe amount in pregnancy

caffeine

• less than 200 mg a day

• can cause dehydration and nausea

• if mom had a high intake pre-pregnancy she should decrease gradually not cold turkey bc of withdrawal symptoms

artificial sweeteners (aspartame)

• contain phenylalanine which causes PKU (cannot process protein) in babies

gluten free women are at a higher risk of

• lacking folate

PICA is strongly associated with

iron deficiency

• screening for pica at every first prenatal visit, every trimester and when s/s of anemia appear

safe food preparation

• no cold cuts unless heated up

• no raw food

why should pregnant women sit up after meals

helps with pyrosis (heart burn) and nausea

adolescent pregnancies are deficient in

• calcium and iron

• calcium should be taken with vitamin D

women who hav had bariatric surgery

• lack in folate, vitamin B and iron

• may have stricter dietary restrictions

biophysical risk factors

• originates from mom or fetus

• may effect development or functioning if 1 or both

• Genetic disorders, nutritional and general health status, and medical or obstetric-related illnesses

conditions that influence nutritional status

• young age;

• three pregnancies in the previous 2 years;

• tobacco, alcohol, or drug use;

• inadequate dietary intake because of chronic illness or food fads;

• history of bariatric surgery;

• inadequate or excessive weight gain;

• and hematocrit value less than 33%.

psycosocial risk factors

• maternal behaviors and adverse lifestyle that have a negative effect on mother or baby

• emotional distress / depression

• substance use

• IPV (higher risk for pregnant)

• unsafe cultural practices

• substance use

what effect can smoking have on baby

• low birth weight

• high baby mortality rate

• high miscarriage rate

• pre labor ROM

what can caffeine do to fetus

• intrauterine growth restriction

what effect can alcohol have on bay

• fetal alcohol syndrome

• learning disabilities

• hyepracticivty

sociodemographic

• arise from mother and her family/ home environment

• may include;

• lack of prenatal care

• low income

• unmarried

• adolescent or AMA

• ethnicity - black women have higher rate of preterm births

environmental risk factors

• hazards in workplace or environment

• chemicals, gas, radiation

daily fetal movement count / kick count

• monitors fetal movement

• lack of movement indicates lack of O2/ hypoxemia

• can be done at home

rules of DFMC baby movement

• normally - 30 “kicks” in 1 hour but mom only feels 70-80%

• if mom feels less than 3 kicks, baby needs NST

fetal alarm signal

less than 12 kicks in 1 hour

when could fetal movement be decreased other than in hypoxemia

• in fetal sleep

• taking meds like CNS depressants, alcohol or smoking

• obesity/ large abd circumference

bladder requirements in abd vs vaginal ultrasound

• abd - full bladder

• vaginal - empty bladder

what can be detected in unltrasdound in 1st trimester (9)

• ectopic pregnancy

• fetal heart rate @ 6wks using vaginal ultrasound

• gestational age

• viability

• multiple gestation

• cause of vaginal bleeding

• chorionic villi sampling

• maternal abnormalities - cystic fibrosis, bicronuate uterus etc.

• nuchal translucency

nuchal trranslucency

• measure function of nuchal cord

• can be done at 10-14 wks

• 3mm or more can indicate chromosomal abnormalities

what can be detected in unltrasdound in 2nd trimester

• confirm dates

• poly or ogliohydraminos

• detect congenital anomalies

• detect IUGR

• placenta location

• visualization in amniocentesis

• evaluating pre term labor

• everything that can be done in 1st trimester

where should the placenta be

at least 2cm from cervix @ 16 weeks

what can be detected in unltrasdound in 3rd trimester

• detecting macrosomia - large for gestational age

• fetal position

• placenta previa or abruption/ placenta maturity

• biophysical profile

• doppler flow studies

• everything that can be done in 2nd trimester

doppler blod flow anaylsis

• estimates blood flow in umbilical arteries

biophysical profile

• noninvasive ultrasound test

• assesses fetus on acute and chronic markers

• amniotic fluid index

• fetal breathing movement

• Nonstress test (fetal heart rate reactivity) - only non-ultrasound

• fetal movement and tone

if a pocket is measure less than 5 cm

ogliohydraminos

if a pocket is measure greater than 25 cm

polyhydraminos

what would we do for a baby who scores an 8-10

• normal/ low risk for chronic asphyxia

• repeat testing

what would we do for a baby who scores a 6

• suspect chronic asphyxia

• 36 weeks or above with lung maturity - consider delivering

• less than 36 weeks without lung maturity - repeat is 4-6 hours

• deliver if oligohydraminos is present

what would we do for a baby who scores a 4

• suspect chronic asphyxia

• if baby is 36 weeks or more: deliver

• if baby is less than 32 weeks, repeat test

what would we do for a baby who scores 0-2

• strongly suspect chronic asphyxia

• extend testing time to 120 minutes

• if score is 4 or less baby needs to be delivered regardless of age

MRI

• non invasive

• no injection or ionizing radiation

• little effect on pets but may be given sedative to reduce movement

what can MRI evaluate

• fetal structure and growth

• placenta

• amniotic fluid volume

• maternal structure

• biochemical status of tissues and organs

• soft tissue, metabolic or functional anomalies

biochemical testing and examples

• involves biologic exam and chemical determinants

• amniocenteses

• percutaneous umbilical blood sampling

• chorionic villi sampling

• maternal bood testing

amniocenteses

• takes amniotic fluid, not done before 14 weeks, when uterus becomes abd organ and when there is enough fluid

• genetic testing

• fetal lung maturity

• fetal hemolytic disease

risks of amnio for mom

• amniotic fluid leakage

• hemorrhage

• fetal-maternal hemmorage with possible Rh isommunization (give rogan if she is Rh-)

• infection

• may cause labor

• placenta abruption

• damage to intestines or bladder

• amniotic fluid embolism

amniotic fluid embolism

• obstetric emergency where amniotic fluid or fetal cells enter the mother's bloodstream, triggering a catastrophic allergic-like reaction.

• It causes sudden cardiovascular collapse, severe breathing difficulties, and hemorrhage, typically during labor or immediately after delivery.

Coombs test

• tests RH compatibility

• and other antibodies that put baby at risk fr incompatibility with maternal antigens

L/S ratio

measures surfactant and lung function

AFP measures

• neural tube defects

indications for use of amniocentesis

• AMA (35 and up)

• older paternal age (40-50)

• parents are carriers of genetic disorders (sickle cell, tay-sachs, cystic fibrosis)

• women with a previous child with chromosomal abnormality/ fetal defect detected in pregnancy

chorionic villi sampling

• done in 1st trimester (10-13 wks)

• rapid results

• removes small portion of fetal side of placenta

• cervically or abdominally

• used to be a risk if fetal limb reduction but it is relatively safe

percutaneous umbilical blood sampling

• AKA cordocentesis or funipuncture

• direct access to fetal circulation during 2nd and 3rd trimesters

• needle inserted directly into umbilical cord under ultrasound guidance

• bleeding from puncture site is the most common complication

• transient fetal bradycardia can also occur

Maternal serum alpha-fetoprotein (MSAFP)

• gestational age must be accurate for testing to be accurate

• ideally done 16-18 weeks , but can be done 15-20wks

• screens NTDs - 85-92% of anencephaly detected early

• should be done on all pregnant women

• if levels are high, ultrasound is indicated

Multiple marker screens

• screening to detect fetal chromosomal abnormalities, particularly trisomy 21 (down syndrome)

quad test

• measure MSAFP, unconjugated estriol, hCG, and inhibin

• screens for trisomy 21 and 18

cell free DNA

• provides definitive dx noninvasiveley for fetal Rh status, gender, and certain paternally transmitted gene disorders

• optimally performed at 10 -12 wks of gestation

• less sensitive in women who are obese

Non stress test

• measures fetal HR activity

• not done during labor

• either reactive (normal) or nonreactive (abnormal)

• may be down with vibroacoustic stimulation

vibroacoustic stimulation

• done with NST if fetal HR cannot be found or if baseline is nonreacitve

• uses sound + vibration for 3 seconds over baby’s head to stimulate

• if no response wait 1 minute intervals, can be repeated 3 times

• must be able to elicit response within 3 minutes

Contraction Stress test

• assesses how well baby can tolerate contractions

• nipple stimulation (increases oxytocin) or oxytocin stimulated

• done for high risk babies to see if mom can deliver vaginally

• time consuming and invasive

Contraction Stress test results

• negative - what we want! no change in FHR

• Positive - FHR decels are present

Contraction Stress test contraindications

• preterm labor

• placenta previa

• vasoprevia - umbilical vasculature in wrong position

• multiple gestation

• previous classical incision (vertical cut to uterus) - mom should have c-sections going foward bc of damage to uterus

high risk pregnancy emotional effects on mom

• May exhibit anxiety, low self-esteem, guilt, frustration, vulnerability and inability to function

• May affect parental attachment, accomplishment of the tasks of pregnancy, and family adaptation to the pregnancy

nurses role

• education

• anticipatory planning

• counseling / referrals for counseling

• support system

• may perform some tests (NST, CST, BPPs)

maternal phases of adapting to becoming a mother

• phase 1 - accepts the biological fact of pregnancy

• phase 2 - accepts the growing fetus as distinct from herself

• phase 3 - she prepares realistically for the birth and parenting of the child

partner adaptation to pregnancy

• announcement phase - accepting of pregnancy

• moratorium phase - stops activity and accepts the reality

• focusing phase - assuming parent role and role in labor

fundal height assessment

• bladder must be empty

• measured sam way each time

• should not be supine for very long - r/o supine hypotension

• at 18-30 weeks, the height should match up with the weeks (15 weeks - 15 cm)