NCLEX-RN: Maternal–Newborn Nursing

Maternal–Newborn Nursing: NEWBORN

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Family Planning

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Infertility

Focus topic: Maternal–Newborn Nursing

Definition: The inability to conceive after 1 year of regular intercourse with no contraceptive measures, or the inability to deliver a live fetus after three consecutive conceptions.

Characteristics
A. General statistics indicate that two-thirds of couples achieve pregnancy within 6 months and 90% within 1 year—approximately 8–10% of couples in United States are infertile.
B. Approximately 40–50% of all infertility is attributed to the female.

  • Following investigation and treatment, 50–70% achieve pregnancy.
  • Of the 30–50% who do not achieve pregnancy, 10–20% have no pathologic basis for infertility.

Assessment
A. Causes of infertility.

  • Female.
    a. Functional: hormonal dysfunction causing insufficient gonadotropin secretions.
    b. Anatomic: ovarian factors, uterine abnormalities, tubal, peritoneal, and cervical factors.
    c. Inflammation or adhesions, chronic infections.
    d. Psychological problems.
    e. Immunologic reaction to partner’s sperm.
  • Male.
    a. Semen disorders—volume, motility, or density; abnormal or immature sperm.
    b. Systemic disease such as diabetes.
    c. Genital infection.
    d. Disorders of the testes.
    e. Structural abnormalities.
    f. Genetic defects.
    g. Immunologic disorders.
    h. Chemicals, drugs, and environmental factors.
    i. Psychological problems.
    j. Sexual problems.

B. Tests for infertility.

  • Female.
    a. Complete physical exam and health history.
    b. Basal body temperature graph.
    c. Endometrial biopsy—luteal phase, 2–3 days before menstruation.
    d. Hormone analysis: progesterone, prolactin, FSH, LH, estradiol, blood levels.
    e. Tests to determine structural integrity of the tubes, ovaries, and uterus (ultrasound: abdominal or transvaginal, hysterosalpingogram, laparoscopy).
  • Male.
    a. Detailed history and physical examination.
    b. Semen analysis (most conclusive) (> 2.0 mL, pH 7.0–8.0; sperm count > 20 million/mL, > 50% motility; > 50% normal forms).
    c. Other laboratory tests: gonadotropin assay, serum testosterone levels, and urine 17-ketosteroid levels.
    d. Testicular biopsy.
    e. Ultrasound—structural integrity of spermatic cord, ejaculating ducts, seminal vesicles, and vas deferens.

C. Treatment.

  • Female.
    a. Identification and correction of underlying abnormality or dysfunction.
    b. Hormone therapy: Clomid (clomiphene).
    c. Surgical restoration.
    d. Drug therapy.
  • Male.
    a. Correction of anatomic dysfunctions or infections.
    b. Proper nutrition with vitamin supplements.
    c. Hormone supplements: testosterone or chorionic gonadotropin.
  • Couples.
    a. Male-female interaction studies.
    b. Counseling for sexual dysfunctions (education, counseling, or therapy).
    c. Intrauterine insemination (using artificial insemination).
    (1) Sperm (collected within 3 hours of coitus) inserted via a catheter into uterus.
    (2) Option of donor sperm—sperm count and/or motility low or if single woman, etc.
    d. In vitro fertilization (IVF)—multiple ova harvested from woman (using large-bore needle).

Implementation
A. Education of couple.

  • Information about diagnostic and treatment techniques.
  • Information about reproductive and sexual function and factors that may interfere with fertility.

B. Provide emotional support.

  • Encourage couple to discuss frustration, anger, etc., and express feelings.
  • Suggest couple join groups to share concerns with other couples.

C. Explore alternatives such as adoption.
D. Provide information and preparation for surgery, if necessary or reproductive alternatives (artificial insemination, in vitro fertilization, etc.).

Influences on Parenthood
A. Tendency toward smaller families.
B. Career-oriented women who limit family size or who do not want children.
C. Early sexual experimentation, necessitating sexual education, contraceptive information.
D. Tendency toward postponement of children.

  • Until education is completed.
  • For economic factors.

E. High divorce rates.
F. Alternate family designs.

  • Single parenthood.
  • Communal family.

Maternal–Newborn Nursing: Issues of Contraception

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: General Concepts

Focus topic: Maternal–Newborn Nursing

A. General concepts.

  • Dealing with individuals with personal ideas/ beliefs regarding contraception.
  • No perfect method of birth control.
  • Method must be suited to individual.
  • Individuals involved must be thoroughly counseled on all available methods and how they work, including advantages and disadvantages.
  • Once a method is chosen both parties should be thoroughly instructed in its use.
  • Individuals involved must be motivated to succeed.

B. Effectiveness depends on:

  • Method chosen.
  • Degree to which couple follows prescribed regimen.
  • Thorough understanding of method.
  • Motivation on part of individuals concerned.

Maternal–Newborn Nursing: Role of Nurse

Focus topic: Maternal–Newborn Nursing

A. Education of client in various methods available, their effectiveness, and their side effects.
B. Help clients explore their feelings regarding birth control and what they find acceptable and not acceptable.
C. Create open, relaxed atmosphere, allowing clients to express concerns and feelings about birth control.
D. Thorough explanation of how method works.
E. Instruction of client in possible complications and side effects.

Maternal–Newborn Nursing: Natural Contraceptive Methods

Focus topic: Maternal–Newborn Nursing

A. Periodic abstinence: 75% effective.

  • Based on three principles.
    a. Ovulation usually occurs 14 days before period begins.
    b. An ovum may be fertilized 12–24 hours after release from ovary.
    c. Sperm usually survive only 24–48 hours in the uterine environment.
  • If coitus is avoided during the fertile period, pregnancy should not occur.
  • Cervical mucus (Billings): Couple avoids intercourse during peak 72-hour period of cycle, when mucus becomes clear, stringy, stretchable, and slippery.
  • Basal body temperature (BBT): Avoid intercourse just prior to or day temperature drops and for 72 hours.
    a. After temperature drops, during ovulation, and rises and fluctuates until 2–4 days prior to menstruation.
    b. BBT thermometer measures in tenths (0.1); can use tympanic or digital.
  • Calendar method—also known as “rhythm.”
    a. Assumes that ovulation occurs 14 days before menstruation, sperm are viable for 5 days, and ovum can be fertilized for 24 hours.
    b. Determine fertile period after recording menstrual cycle for 6 months: subtract 18 days from length of shortest cycle and 11 days from longest cycle; couple abstains during fertile period.
    c. Least reliable; should be used together with BBT or Billings.

B. Coitus interruptus: 60% effective.

  • Requires withdrawal of penis before ejaculation.
  • Preejaculatory fluid may contain sperm.

C. Lactation—unreliable (not a viable option).

  • Breastfeeding has contraceptive effect.
  • Prolactin’s inhibition of luteinizing hormone, which maintains menstruation.
  • Provides protection for 3–6 months.

Maternal–Newborn Nursing: Mechanical Methods

Focus topic: Maternal–Newborn Nursing

A. Condom (male or female): 95–98% effective with proper application.

  • Acts as mechanical barrier by collecting sperm and not allowing contact with vaginal area.
  • Prevents spread of disease.

B. Diaphragm: 80% effective; with proper use, 94%.

  • Functions by blocking external os and closing access to cervical canal by sperm. It is a mechanical barrier.
  • Must be used in conjunction with vaginal cream or jelly to be effective.
  • Toxic shock syndrome may occur; decrease risk by prompt removal 6–8 hours after intercourse and not using during menstruation.
  • Teach client signs of toxic shock: sudden onset of fever > 101.1°F (38.4°C), hypotension (orthostatic dizziness, systolic BP < 90), risk, fatigue, malaise.

C. Contraceptive sponge: 80–90% effective.

  • Inserted deep into vagina, sponge releases spermicide.
  • Leave in place for at least 6 hours after intercourse.
  • Decreases risk of STDs.
  • May be risk of developing toxic shock syndrome.

D. Cervical cap: 90% effective.

  • Rubber cap with spermicide placed over cervical opening.
  • May decrease risk of STD.

E. Intrauterine devices (IUDs): 95% effective.

  • Medicated with copper or progesterone.
    a. Copper in place up to 10 years; damages sperm in transit to tubes, prevents fertilization.
    b. Progesterone changes cervical mucus and endometrium to prevent fertilization.
    c. More rapid transport of ovum through tube reaching endometrium before it is “ready” for implantation.
    d. IUD may cause substances to accumulate in uterus and interfere with implantation.
    e. IUD may stimulate production of cellular exudate, which interferes with the ability of sperm to migrate to fallopian tubes.
  • Usually made of soft plastic or nickel– chromium alloy.
  • Complications: perforation of uterus; infection: increased incidence of PID; spotting between periods; heavy menstrual flow or  prolonged flow; and cramping during menstruation(less with progesterone IUD); allergic rash.
  • Disadvantages: increased risk of PID, need to check for presence of IUD (thread) after menstruation.

Chemical Methods
A. Combined or single hormone contraceptive: 99% effective.

  • Contraceptive effect occurs by:
    a. Artificially raising the blood levels of estrogen and/or progesterone, thereby causing inappropriate release or preventing the release of FSH and LH. Without FSH, the follicle does not mature and ovulation fails to take place.
    b. Endometrial changes.
    c. Alteration in cervical mucus, making it hostile to sperm.
    d. Altered tubal function.
  • Types of birth control pills.
    a. Combined: contains both estrogen and progesterone.
    b. Sequential (mimics normal hormonal cycle): estrogen given alone for 15–16 days, followed by combination of estrogen and progestin for the next 5 days.
    c. Progestin only (99+% effective; called mini-pill): inhibits ovulation, thickens and decreases amount of cervical mucus, thins endometrium, and alters cilia action in fallopian tubes; contains less progestin and no estrogen so slightly less effective. Good option for women who can’t take estrogen or who are over age 35 and smoke.
  • Other types of combined hormones.
    a. Injection.
    (1) Depo-Provera (medroxyprogesterone): IM injection of a progestin administered every 12 weeks; suppresses ovulation.
    (2) Lunelle (medroxyprogesterone acetate and estradiol cypionate) given q 1 mo.
    b. Transdermal patch: q 1 week × 3 weeks.
    c. Vaginal ring: delivers hormones, worn for 3 weeks; self-insertion.
  • Minor side effects, which usually diminish within a few months: breast fullness and tenderness; edema, weight gain; nausea and vomiting; chloasma; breakthrough bleeding; and mood changes.
  • More serious side effects: thrombophlebitis; pulmonary embolism; hypertension.
    a. Teach signs and symptoms: pain (chest/ abdominal, leg), shortness of breath (SOB), headache, dizziness, numbness, visual/speech problems.
    b. Mnemonic of warning signs—ACHES (abdominal pain, chest pain, headache, eye problems, swelling and/or aching in legs).
  • Contraindications: pregnant, smokes > 20 cigarettes/day; > 35 years, has headaches or neurological symptoms; immobile or surgery on legs; BP > 160/100; diabetes of 20+ years with vascular disease.

B. Chemical agent: nonoxynol-9 or octoxynol-9.

  • Agent acts by killing or paralyzing sperm; may kill STD agents.
  • Agent acts as a vehicle for spermicide as well as a mechanical barrier through which sperm cannot swim.
  • Available forms are foams, creams, jellies, or suppositories.
  • Should not use nonoxyl-9 if at risk for HIV.

C. Implants: more than 99% effective.

  • Implanon and Nexplanon (etonogestrel): a single plastic rod/capsule inserted under skin, which releases progestin for up to 3 years, suppressing ovulation.
  • Good option for women who are over age 35 and smoke.

D. Emergency postcoital contraception.

  • Within 72 hours of sex, a specific number of pills are taken to inhibit ovulation.
  • Copper T-380A IUD is inserted within 5–7 days after sex. Prevents implantation by creating a sterile inflammatory response.

Maternal–Newborn Nursing: Operative Sterilization Procedures

Focus topic: Maternal–Newborn Nursing

A. Vasectomy.

  • Surgical procedure with local anesthesia on outpatient basis.
    a. Incision made over ductus deferens on each side of scrotum; sperm ducts isolated and severed.
    b. Ends ligated, lumen coagulated, clipped or polyethylene tubing used with a stopcock for potential reversal.
  • Client instruction for care.
    a. Apply ice with pain or swelling.
    b. Use scrotal support for 1 week.
    c. Inform client that it takes 4–6 weeks and 3–36 ejaculations to clear sperm from ductus.
    d. Sperm samples (two or three) should be checked for sperm count.
    e. Client rechecked at 6 and 12 months to ensure fertility has not been restored by recanalization.
  • Possible side effects of procedure.
    a. Hematoma, sperm granulomas, and spontaneous reanastomosis.
    b. For those who wish to reverse process, 30–85% are successful.

B. Tubal ligation most common method.

  • Accomplished by abdominal or vaginal procedures; most common method is transection of fallopian tubes.
    a. Tubes are isolated, then crushed, ligated or plugged (newer reversible procedure).
    b. The postpartum and mini-laparotomy procedures require hospitalization.
    c. A newer procedure, laparoscopic sterilization, requires an incision at the umbilicus; the tube is coagulated and may be transected.
  • Complications of procedure include bowel perforation, infection, hemorrhage, and adverse anesthesia effects.
    a. Reversal of tubal ligations results in overall pregnancy rate of 15%.
    b. Three-quarters of these pregnancies result in live births, and 10% are tubal pregnancies.

C. Total hysterectomy (removal of uterus and ovaries) is permanent method of sterilization.

Maternal–Newborn Nursing: Therapeutic Abortion

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: General Considerations

Focus topic: Maternal–Newborn Nursing

A. Legality.

  • Abortion is now legal in all states as the result of a Supreme Court decision in January 1973.
  • It is regulated in the following manner.
    a. First trimester—decision between client and physician.
    b. Second trimester—decision between client and physician (state may regulate who performs the abortion and where it can be done).
    c. Third trimester—states may regulate and prohibit abortion except to preserve the health or life of the mother.

B. Indications.

  • Medical: psychiatric conditions or diseases such as chronic hypertension, nephritis, severe diabetes, cancer, or acute infection such as rubella; possible genetic defects in the infant or severe erythroblastosis fetalis.
  • Nonmedical: socioeconomic reasons, unmarried, financial burden, too young to care for infant, rape or incest.

C. Preparation of the individual.

  • Advise client of available sources of abortion.
  • Inform client as to what to expect from the abortion procedure.
  • Provide emotional support during decision making period.
  • Maintain an open, nonjudgmental atmosphere in which the individual may express concerns or guilt.
  • Encourage and support the individual once the decision is made and after surgery.
  • Give information about contraceptives.

D. Complications and effects.

  • Abortion should be performed before the 12th week, if possible, because complications and risks are lower during this time.
  • Complications.
    a. Infection.
    b. Bleeding.
    c. Sterility.
    d. Uterine perforation.

Techniques

A. First trimester.

  • Dilatation and curettage (D&C).
    a. Cervical canal is dilated with instruments of increasingly large diameter.
    b. Fetus and accessory structure is removed with forceps.
    c. Endometrium is scraped with curette to ensure that all products of conception are removed.
    d. Process usually takes 15–20 minutes.
  • Vacuum aspirator.
    a. Hose-linked curette is inserted into dilated cervix.
    b. Hose is attached to suction.
    c. The vacuum aspirator lessens the chance of uterine perforation, reduces blood loss, and reduces the time of the procedure.
    d. Laminaria tent (cone of dried seaweed): used after 8 weeks’ gestation helps to dilate cervix; reduces cervical laceration and bleeding during vacuum aspiration.
    e. Prostin (prostaglandin gel) may also be used to soften the cervix.
  • Mifeprex (mifepristone; RU486)—antiprogestin hormone; can be used up to 9 weeks, more effective earlier; may be combined with a prostaglandin agent (Cytotec [misoprostol]).

B. Second trimester.

  • Hysterotomy.
    a. Incision is made through abdominal wall into uterus.
    b. Procedure is usually performed between weeks 14 and 16 of pregnancy.
    c. Products of conception are removed with forceps.
    d. Uterine cavity is curetted.
    e. Tubal ligation may be done at same time.
    f. Client usually requires several days of hospitalization.
    g. Operation requires general or spinal anesthesia.
  • Intra-amniotic injection or amniocentesis abortion (used in less than 1% of all abortions).
    a. Performed after 14–16 weeks of pregnancy.
    b. From 50–200 mL of amniotic fluid are removed from the amniotic cavity and replaced with hypertonic solution of 20–50% saline instilled through gravity drip over a period of 45–60 minutes.
    c. Increased osmotic pressure of the amniotic fluid causes the death of the fetus.
    d. Uterine contractions usually begin in about 12 hours and the products of conception are expelled in 24–30 hours.
    e. Oxytocic drugs may be given if contractions do not begin.
    f. Complications.
    (1) Infusion of hypertonic saline solution into uterus.
    (2) Infection.
    (3) Disseminated intravascular coagulation (DIC) disease may develop during procedure.
    (4) Hemorrhage.
  • Prostaglandins (most common for second trimester).
    a. These hormonelike acids cause abortion by stimulating the uterus to contract.
    b. May be administered in suppository form, as a gel, or by intrauterine injection.

Abortion Procedure

Focus topic: Maternal–Newborn Nursing

Assessment
A. Observe for excessive bleeding.
B. Assess for symptoms of infection.
C. Assess for hypernatremia in saline abortions.
D. Check for nausea and vomiting.

Implementation
A. Administer preoperative medications.
B. Ensure that client understands the procedure.
C. Offer emotional support and provide opportunity for client to express feelings.
D. Monitor IV.
E. Check vital signs pre- and postoperatively.
F. Administer pain medications as ordered.
G. Instruct client to watch for signs of excessive bleeding (more than a normal menstrual period)and infection (elevated temperature, foul-smelling discharge, persistent abdominal pain).
H. Administer oxytocic drug as ordered.
I. Administer RhoGAM as ordered for an Rhnegative client.
J. Offer fluids as tolerated, after vital signs are stable and client is alert and responsive.
K. Counsel regarding birth control methods.
L. Stress importance of follow-up visit to decrease risk of complications; often have a pregnancy test.

COMMON DRUGS IN OBSTETRICS

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing
Maternal–Newborn Nursing

NUTRITIONAL GUIDELINES FOR PREGNANCY

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing

RECOMMENDED DAILY DIETARY ALLOWANCES FOR PREGNANCY AND LACTATION

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing
Maternal–Newborn Nursing

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