Preventive pediatrics Child health nursing First year MSc nursing

1. MATERNAL HEALTH AND ITS
INFLUENCE ON CHILD HEALTH
Ms ARIFA T N
FIRST YEAR M.Sc NURSING, MIMS CON

2. INTRODUCTION
 Most pregnancies are normal and result in a
healthy newborn.
 Pregnant women can be unknowingly exposed
to potentially harmful physical, psychosocial,
Behavioral, or environmental conditions that
can increase pregnancy risk
 There is growing evidence of the genetic
influence upon some perinatal risk factors and
of a link between exposure to environmental
triggers and perinatal outcomes

3. INTRODUCTION
 Patient education, emotional support, and
assistance with lifestyle alterations necessary
for healthy pregnancy are key components of
prenatal care
 Evaluation of maternal risk factors can help
anticipate many of the neonates who will be at
increased risk for problems at birth

4. MATERNAL RISK FACTORS
 There is no way to accurately predict every
neonate who will be at risk since a cause-and-
effect relationship between high-risk maternal
characteristics or behaviors and poor
outcomes is not always clearly defined
 One of the most essential ways to decrease
problems of prematurity, LBW, and perinatal
death is to promote optimal pregnancy health.

5. • Diet
• Smoking
• Alcohol use
• Substance abuse
Modifiable
• Maternal age
• Ethnicity
• Genetic inheritance,
• Preexisting health problems
Nonmodifiable
MATERNAL RISK FACTORS
 Risk factors may be either modifiable or
nonmodifiable. Eg:,

6. MATERNAL RISK FACTORS
 The presence of one risk factor may lead to
other risk factors causing an additive effect.
For example, a pregnant woman who lacks financial
resources might also have a poor obstetric history, an
inadequate nutritional intake, increased stress, and
nicotine addiction.

7. MATERNAL RISK FACTORS
 Maternal risk factors consist of demographic,
behavioral, and psychosocial factors, as
well as maternal medical conditions and
pregnancy related conditions
 Demographic risk factors include,
 Ethnicity
 Age
 Socio economic status
 Occupation, and
 Environmental or work-related exposures

8.  Psychosocial risk factors include
 Social, behavioral, stress related or maternal
psychological conditions
 Medical risk factors
 The IOM categorizes medical risk factors into
immutable factors which can’t be changed and
mutable factors which can possibly be altered

9.  Immutable factors include factors
which predate the pregnancy such as
 Obstetric history (i.e., previous history of
infertility, PTB, or pregnancy loss)
 Maternal characteristics
 Short stature
 Low pre pregnancy weight
 Low body mass index (BMI)
 Pregnancy-related conditions such as
 Multiple gestation
 Pregnancy-induced hypertension (PIH)
 Gestational diabetes.

10.  Mutable risk factors include
behavioral risk factors the mother
has either prior to or during
pregnancy that can possibly be
harmful to the fetus, such as
 Inadequate dietary intake
 Smoking
 Substance abuse (drugs or alcohol).

11. Maternal age
 The maternal age at the time of the birth
of the first child ranges from an average
of 15.5 to 20.5 years the in traditional
forager, agricultural, and horticultural
societies and from 25.1 to 29.9 years in
more developed nations
 Teen pregnancy increases the risk of
adverse outcomes such as
 Preterm delivery, LBW, low 5-minute Apgar
score, or early neonatal death

12. Maternal age
 After birth, infants of younger mothers (<
19 years of age) had an increased risk
for readmission to the hospital within the
first 6 weeks after discharge.
 There are also lifelong disadvantages for
younger teen mothers who have less
years of formal education pregnancy.

13. Maternal age
 Pregnant adolescents who are uneducated most
likely will not use contraception, may not
recognize danger signs in pregnancy that
something is wrong, or may not even seek
prenatal care

14. Maternal age
 Advanced maternal age refers to women who are older
than 35 at the estimated date of delivery
 Advanced maternal age poses increased risks for
 Decreased fertility
 Chromosomal abnormalities in the infant
 Spontaneous abortion
 Ectopic pregnancy
 Preterm delivery
 Stillbirth
 Late fetal and early perinatal death rates are higher
for pregnant women between ages 45 and 54 than
for any other age groups

15. Maternal age
 Older pregnant women are at an increased risk
for medical problems associated with aging such
as diabetes or PIH
 Advanced maternal age creates genetic risks
because as the woman gets older the genetic
material contained within her ova ages
 Trisomy 21 (Down syndrome), trisomy 18, and
trisomy 13 are examples of genetic problems
resulting from errors in cell division

16. Psychological stress in
pregnancy
 Stress is an interaction between the person
and environment in which there is a perceived
discrepancy between the demands of the
environment and the individual’s resources
(i.e., psychological, social, or biological) for
dealing with it

17. Psychological stress in
pregnancy
 During pregnancy women may
experience many types of
stressors about
 Finances
 Work situations
 Difficult relationships
 Health concerns of self or other
family members, or other factors
 Emotional stress may include
feelings of anxiety, fear, tension,
depressions, or sadness

18. Psychological stress in
pregnancy
 Acute stressors can occur due to
life events such as the
 death or serious illness of a loved
one.
 Death of the father of the
developing fetus or of a first-
degree relative of the mother
during mid-pregnancy.
 There was increased risk for
shortened gestation if the stressor
occurred in the fourth or fifth
month of pregnancy, while
vulnerability to LBW or SGA

19. Psychological stress in
pregnancy
 The exact mechanism by which maternal
stress causes PTL is not fully understood, but
it is thought to occur by one of two
mechanisms.
 Corticotrophin-releasing hormone released as a
by-product of maternal stress could stimulate
neuro-endocrine pathways within the maternal-
fetal-placental unit that trigger labor
 Maternal stress could cause increased maternal
and fetal susceptibility to inflammation and
infection, triggering labor through an immune-
inflammatory pathway;

20. Obstetric factors
 Obstetric history is a good indicator of the
presence of maternal risk factors.
 Women with previous obstetric complications are
more at risk for problems with the current
pregnancy.
 Previous obstetric history of infertility
 Stillbirth
 Preterm infant
 Infant with growth restriction or congenital anomalies
 Genetic problems
 Complications during pregnancy or birth, or
 Other poor outcomes are clues that indicate that the
pregnancy must be closely monitored.

21.  Important obstetric factors that can compound
pregnancy risk are the
 Adequacy of prenatal care,
 The number of previous pregnancies,
 Inter pregnancy level
 The use of assistive reproductive
technology(ART), and
 Postterm pregnancy

22. Prenatal care
 Prenatal care that begins in the first trimester of
pregnancy and continues until birth helps promote
good birth outcomes
 Most women seek prenatal care during the first
trimester of pregnancy
 UNICEF and WHO have set a worldwide goal for
a minimum of four prenatal visits during
pregnancy
 Worldwide, approximately 72% of women have at
least one prenatal visit, and 42% of women
(excluding China) have four or more prenatal
visits

23. Prenatal care
 Inadequate prenatal care increases the risk for
 LBW
 PTB and
 Perinatal death
 High post neonatal death rates seen in infants
of women who did not have prenatal care
might be associated with lack of access to
care providers or lack of use of pediatric
medical care

24. Parity
 Parity or number of previous deliveries is
another risk factor to consider.
 Parity is difficult to disassociate from age as
women with higher parity are usually older.
 The risk for having the following increases as
parity increases,
 LBW infant
 Preterm delivery
 Abruptio placenta
 placenta previa

25. Interpregnancy level
 Interpregnancy level is defined as the amount of
time between delivery of a baby and the
subsequent conception of another child.
 Short interpregnancy level of less than 6 months
increases the risk for maternal complications,
including
 Third-trimester bleeding
 PROM
 Puerperal endometritis
 Anemia, and
 Maternal death.

26. Assistive reproductive
technology
 ART is any procedure or medical
treatment used to assist a woman to
achieve pregnancy.
 ART is an option for many couples who
have a history of infertility

27. Assistive reproductive
technology
 ART methods include
 the use of medications to stimulate
ovulation and release of eggs, or
 procedures where eggs and sperm are
removed and mixed outside of the body to
achieve fertilization
 ART increases the risk for
 Multiple pregnancy
 Prematurity, and
 LBW

28. Postterm pregnancy
 Postterm pregnancy is defined as a pregnancy
that continues past 42 weeks (294 days) or 14
days past the estimated due date (American
College of Obstetricians and Gynecologists
[ACOG], 2004)
 Incidence is in about 7% of all pregnancies.
 The cause of postterm pregnancy is not known,
but it occurs more often with
 Male fetuses
 Genetic basis.
 Inaccurate dates used to calculate the estimated
date of confinement.

29. Postterm pregnancy
 Ultrasound dating of pregnancy is
considered to be accurate if done during
the first trimester; however, ultrasound
dating of pregnancy has a margin of error.
 Postterm infants are more likely to have
 Macrosomia,
 Prolonged labor or
 Cephalopelvic disproportion (CPD) with
 Increased risk for cesarean section,
 Shoulder dystocia
 Increased risks of possible musculoskeletal
injury
(i.e., Fractured clavicleor brachial plexus injury)

30. HCBs (health-compromising
behaviors)
 HCBs such as smoking, illicit drug use, or
alcohol use can compromise overall maternal
health during pregnancy and can negatively
influence fetal well-being.

31. Smoking
 Smoking is a major predictor of LBW possibly
due to impaired oxygen delivery (hypoxia) and
nutrient delivery from the mother to fetus.
 Infants of mothers who smoke have an
increased risk of,
 Spontaneous abortion
 Late fetal death
 Preterm delivery, and
 Neonatal mortality

32. Substance Abuse
 Substance abuse is a concern for childbearing
women of all ages.
 More teenagers are experimenting with drugs,
alcohol, and smoking cigarettes and marijuana
than in the past.
 Marijuana smoking results in carbon monoxide levels
five times higher than cigarette smoking, that limits
fetal growth and oxygenation
 Women under the influence of mind-altering
substances are more likely to make poor choices and
have an increased risk of engaging in unprotected sex
resulting in an unplanned pregnancy

33. Substance Abuse
 Maternal alcohol ingestion during pregnancy
can result in FAS.
 Incidence of FAS may be related to both
environmental exposure and genetic
susceptibility.
 Alcohol is believed to have a direct teratogenic
effect that limits fetal growth and brain growth.

34. Nutrition
 Adequate nutrition prior to conception and
during pregnancy is important for maternal and
fetal health.
 The pregnant woman needs to consume
enough calories and nutrients to meet her own
physiological needs as well as those of the
developing fetus.

35. Nutrition
 Lack of adequate nutrients prior to or during
early pregnancy can lead to birth defects
 Inadequate or excessive weight gain,
 Medical conditions that complicate pregnancy
such as hyperemesis gravidarum
 Dental conditions that compromise the ability to
take in food
 Inadequate resources to access food

36. Nutrition
 Another important nutritional consideration is
prevention of maternal anemia during
pregnancy. Anemia is a serious problem
affecting about half of pregnant women
worldwide.
 Women who are anemic are less likely to
withstand blood loss during delivery and have
increased risks of perinatal death, LBW,
stillbirths, and prematurity (WHO, 2005)
 Promoting adequate nutrition prior to
pregnancy is a key to improving outcomes of
pregnancy

37. Nutrition
 Another important nutritional consideration is
prevention of maternal anemia during
pregnancy. Anemia is a serious problem
affecting about half of pregnant women
worldwide.
 Women who are anemic are less likely to
withstand blood loss during delivery and have
increased risks of perinatal death, LBW,
stillbirths, and prematurity (WHO, 2005)
 Promoting adequate nutrition prior to
pregnancy is a key to improving outcomes of
pregnancy

38. Nutrition
 Maternal obesity is another nutritional
concern for pregnancy. Infants of obese
women (defined as BMI over 30.0 kg/m2) have
more than twice the risk for stillbirth and
neonatal death after adjusting for other factors
including smoking, alcohol, maternal age,
parity, hypertension, and diabetes

39. Nutrition
 Women who ingest food contaminated with
Listeria do not usually feel ill; however, the
fetus can be significantly affected. Eating food
contaminated by microorganisms like Listeria
or substances like heavy metals can cause
abortion, stillbirth, preterm delivery, neonatal
infections, fetal brain or kidney problems, or
even maternal death.

40. Nutrition
 Pica is an interesting dietary practice seen
during pregnancy in almost every culture.
Substances like starch, ice, clay, or dirt are
ingested as a craving in an attempt to possibly
increase iron or calcium intake.
 Pica is not generally harmful to the fetus and
may help alleviate gastrointestinal distress in
pregnant women
 The influence of cultural dietary practices as
potential risk factors can’t be ignored and
must be assessed

41. Over-the-Counter and
complementary Drugs
 Drugs taken during pregnancy can have
harmful effects on the fetus whether they are
controlled substances or over the- counter
medications
 Pregnant women should not take any
medications without consulting with their
health care provider,

42. Over-the-Counter and
complementary Drugs
 Many pregnant women take over-the-counter
or nonprescribed medications during
pregnancy, including complementary therapies
they might not consider to be harmful
 Even vitamins and dietary supplements taken
in excessive dosages can be harmful to the
fetus

43. Environmental Influences
 Exposure by the mother to environmental
toxicants either before or during pregnancy
can precipitate gene–environment interactions
that can alter these molecular interactions,
especiallyb if the exposure to the harmful
substance occurs at critical periods of fetal
development.

44. Environmental Influences
 Two critical periods
 During organogenesis (when fetal organs are being
formed)
 During the fetal period when there is rapid growth of
all systems
 Spina bifida is an example of a gene–environment
interaction
 Environmental hazards are found in air, water, and
food. These seemingly innocuous substances can
contain high levels of contaminants such as
pesticides, heavy metals, and solvents

45. Environmental Influences
 Occurrence of natural or manmade disasters
such as hurricanes, severe ice storms,
earthquakes, chemical spills, or terrorism
 Outcomes of environmental hazards exposure
can be
 Increased rates of spontaneous abortion,
 congenital anomalies,
 decreased fetal growth, and
 changes in maternal mental health status,
 PTB

46. Other Emerging Risk Factors
 Other risk factors that may affect perinatal
outcomes are constantly under investigation.
 Recently, obesity has been identified as an
emerging risk factor for PTB
 Severe maternal snoring and maternal sleep
deprivation in the last trimester of pregnancy
have been linked to an increased risk for fetal
growth restriction or LBW

47. Maternal medical and
obstetric conditions
 Diabetes, hypertension, and bleeding
disorders are some of the most common
maternal complications of pregnancy
worldwide
 These complications can lead to preterm
delivery, perinatal death, or can influence fetal
morbidity. Risk of maternal complications of
pregnancy increases with advanced maternal
age

48. Diabetes
 During pregnancy, regulation of blood glucose
is sometimes difficult since pregnancy creates
a state of insulin resistance and insulin needs
change with each trimester.

49. Diabetes
 Glycosylated hemoglobin levels (HbA1c)
should be maintained to as close to normal
range as possible during pregnancy, especially
during the period of fetal organogenesis
 About 5% of pregnancies are complicated by
gestational diabetes

50. Diabetes
 All pregnant women should be screened for
gestational diabetes through patient history,
presence of clinical risk factors, or
administration of a 50 g 1-hour oral glucose
tolerance test (OGTT) between 24 and 28
weeks gestation
 The ADA recommends a 75-g OGTT at 24 to
28 weeks with blood glucose measurement
when fasting, and at 1 and 2 hours after blood
glucose administration.

51. Diabetes
 Infants of diabetic mothers generally have
 Macroso mia
 Increased risks for birth injuries due to shoulder
dystocia, including fractured clavicles or nerve
palsies.
 Large infants are more likely to be delivered by
cesarean section.
 Infants of diabetic mothers should be closely
monitored for hypoglycemia in the immediate
postbirth period and until feeding is well
established

52. Hypertension in Pregnancy
 Approximately 6% to 8% of
pregnancies are complicated by
hypertensive disorders
 The national high blood
pressure education working
group defined four categories of
hypertension in pregnancy:
 Chronic hypertension,
 Gestational hypertension,
 Preeclampsia, and
 Preeclampsia superimposed on
chronic hypertension

53. Hypertension in Pregnancy
 Hypertension in pregnancy causes
vasoconstriction with subsequent poor
maternal circulatory and placental perfusion
 Decreased utero-placental circulation
compromises the fetus; therefore, it is more
likely to be growth restricted, SGA, or at
increased risk for stillbirth

54. Hypertension in Pregnancy
 Women with PIH are also at increased risk for
abruptio placenta
 Early delivery will be based upon stability of the
mother and outcomes of fetal testing.
 A serious risk for the preeclamptic mother is the
possibility of eclamptic seizures due to cerebral
edema and central nervous system excitability or
progression to the HELLP syndrome

55. Hypertension in Pregnancy
 If the mother’s condition worsens, early
delivery will be elected; however, the ability of
the fetus to survive must be considered
 Corticosteroid administration is advised and
may be beneficial if the fetus is between 24
and 34 weeks gestational age and if the
mother has never had them

56. PROM
 PROM is a cause of preterm delivery and
occurs in about 3% of all births
 Once the membranes rupture, the fetus is at
high risk for problems related to
oligohydramnios, cord compression,
chorioamnionitis, and abruptio placenta

57. PROM
 About 13% of pregnancies complicated with
PROM develop chorioamnionitis.
 Signs of intrauterine infection include fever
greater than 100.4°F (38.0°C), uterine
tenderness, and maternal or fetal tachycardia.
 antibiotic therapy has been demonstrated to
lower the number of infants with respiratory
distress syndrome, death, early sepsis, severe
intraventricular hemorrhage, and severe
necrotizing enterocolitis.

58. Maternal Infections
 Women may be infected prior to pregnancy or
acquire the infection during pregnancy
 Maternal infections can be transmitted to the
infant while in utero across the placenta,
during the birth process, or even during the
postpartum period.

59. Maternal Infections
 Fetal infections can cause congenital
anomalies, LBW, respiratory illness after birth,
or even death. Infectious agents include
protozoal infections, helminthic infections,
sexually transmitted diseases (STDs), viruses,
and bacterial organisms.

60. Maternal Infections
 Every pregnant woman must be screened for
risk factors for infection. Early identification
and treatment of women with infections will
improve both maternal and neonatal outcomes

61. Abruptio Placenta
 Abruptio placenta, or premature separation of
the placenta prior to delivery, is a leading
cause of stillbirth and neonatal mortality
 Placental separation is thought to be due to
 Changes in placental vasculature,
 Thrombosis, and
 Reduced placental perfusion.

62. Abruptio Placenta
 Perinatal death from abruptio placenta is
higher for singletons than for multiples,
possibly due to IUGR, chronic fetal
compromise, LBW, or blood loss from the
abruption, while in multiples a different etiology
could be a factor

63. Postpartum risk factors
 After birth, the five leading causes of infant
death are
 complications of congenital anomalies,
 complications of prematurity
 LBW,
 SIDS,
 result of maternal complications, and
 placental-cord complications

64. Drugs Excreted in Maternal
Milk
 Maternal medications taken while lactating are a
concern as they may alter the milk supply or
cross to the infant though the milk supply
 Psychotropic drugs pose a special concern
since there has been an increase in their use.
These drugs and their metabolites have long
half-lives and are detectable in infant tissues
and the developing brain

65. Drugs Excreted in Maternal
Milk
 Some untoward effects on the
infant from use of prescribed
maternal drugs include,
 Immune suppression,
 Neutropenia,
 Skin rash,
 Central nervous system changes
including irritability, restlessness,
sleepiness, lethargy, or convulsions,
 Gastrointestinal effects such as
feeding problems, vomiting,
diarrhea, slow weight gain, blood in
stool, jaundice, or dark urine.

66. Sudden Infant Death
Syndrome
 SIDS is the leading cause of death in infants in
the postneonatal period in the United States
as well as other developed countries
 Programs such as the AAP Back to Sleep
campaign urged parents to place their infants
on their backs instead of prone for sleeping

67. Sudden Infant Death
Syndrome
 SIDS has been blamed on environmental
factors such as
 Soft bedding,
 Overheating,
 Entanglement in blankets,
 Immunizations,
 Tobacco smoke exposure, or
 Bed sharing with parents or siblings, especially if
a bed partner consumes alcohol

68. Sudden Infant Death
Syndrome
 Nurses need to educate parents to share
information with their childcare providers about
placing the baby on the back to sleep
 Neonatal nurses must continue to educate
each parent about the risk factors for SIDS
and remind parents that the safest place for a
baby is in its own crib in the parents’ room for
the first 6 months.

69. Child Abuse
 Child abuse in infants is sometimes difficult to
identify
 Parents of an injured infant arrive for
emergency treatment and seem severely
distraught and worried about their child’s
injuries

70. Child Abuse
 They often offer reasonable explanations for
the injury that must be ruled out with medical
tests
 New parents are subject to many stressors
that could trigger child abuse such as lack of
sleep, financial strain, and dealing with
inconsolable infants

71. Child Abuse
 Health care providers have a legal and ethical
duty to report cases of suspected child abuse
to child protective service
 Two forms of child abuse are discussed
further:
 Abusive head trauma (AHT), formerly called
shaken baby syndrome (SBS), and
 Munchausen syndrome by proxy (MSBP).

72. Abusive Head Trauma/Shaken
Baby Syndrome
 AHT describes a serious form of head trauma
caused by several mechanisms including
abusive shaking of an infant causing a
whiplash-type injury, blunt trauma, or a
combination of both

73. Abusive Head Trauma/Shaken
Baby Syndrome
 Several types of injuries occur with AHT/SBS.
Intracranial injuries cause direct brain injury
and damage to the axons
 Shearing forces exerted on the veins that
bridge from the dura to the brain cause
intracranial bleeding

74. MSBP
 MSBP is a rare form of child abuse where a
parent, usually a mother, fabricates illness in a
dependent child in order to draw attention to
themselves as the parent of a sick child.

75. MSBP
 Four criteria are required for a diagnosis:
 A parent or guardian fabricates illness in the child,
 The child is presented for medical care,
 The perpetrator denies knowledge of the cause of
the child's illness, and
 The signs and symptoms subside if the child is
separated from the perpetrator

76. MSBP
 Some of the most common types of
fabrications include
 Gastrointestinal (diarrhea), neurologic
(seizures), infections (fevers), dermatologic
(strange rashes), and cardiopulmonary (acute
lifethreatening events).

77. Conclusion
 This session has presented an overview of
some of the many prenatal, intrapartum, and
postpartum risk factors that influence neonatal
health, especially in relation to prematurity and
LBW. The perinatal nurse must be aware of
potential risk factors in order to screen
pregnant women and provide counseling and
support.