for undergraduate nursing students

1. Lecture prepared by
Dr/Rehab Soliman Abd El Aliem

2. General objectives:
At the of this lecture each student will be able to upgrade advanced
knowledge, skills to improve their attitude regarding heart disease.
Specific objectives:
After this lecture each students will be able to:
1- Identify Classification of heart disease.
2-Define Hemodynamic changes during pregnancy.
3- List effects of heart disease on pregnant women.
4-Discus Nursing management.
5-Discus Nursing care during Antenatal period.
6- Illustrate Nursing management for patients with Class III or IV
heart disease.
7-Enumerate Nursing care during the intrapartal period.
8- Discus Nursing care during postpartum period.

4. PARAMETER CHANGE (PERCENT(
Blood volume 50%
Cardiac output 40%
Heart rate
arterial pressure
Critical period in pregnant cardiac women
*Changes start from as – 6weeks
*Max changes around –30 weeks
*Intra partum period
*Just after delivery
*Second week of puerperium

5. *Varies between 0.1 – 4.0 %, average 1% worldwide.
*50% of the cases due to Rheumatic heart disease and
other half due to congenital heart defects .
*Maternal mortality in pregnant cardiac patients is 10%
worldwide, and 12.8% in Egypt.
*Death occure due to overload pulmonary congestion
hypotension hypoxia sudden death

6. *Grade I:asymptomatic with normal activity-No
limitation of physical activity.
*Grade II: Symptoms with normal physical activity-
Slight limitation of physical activity fatigue dyspnea,
palpitation occurring with ordinary activity.
*Grade III: Moderate to marked limitation of physical
activity. Excessive fatigue, dyspnea, palpitation or
angina pain occurring with less than ordinary activity.
*Grade IV: Severe limitation of physical activity-
Inability to carry on any physical activity. Dyspnea at
rest.

7. *Worsening of cardiac status
* bacterial endocarditis, pulmonary edema, pulmonary
embolism, heart failure.
*No long term effect on basic defect

8. Maternal :
*Abortion.
*Preterm labor.
Fetal:
*Fetuses small for gestational age(IUGR).
*Fetus death .
*Congenital heart disease in baby – 5%

9. * Progressive dyspnea or breathlessness
*Fatigue
*Tachycardia
*Chest pain
*Oedema
*Hemoptysis

10. *Anaemia
*Infections
*Hypertension
*Physical labour
*Weight gain
*Multiple pregnancy
*Caffein , alcohol intake
*Drugs – tocolytic

11. *ECG – cardiac arrhythmias, hypertrophy
*Echocardiography – cardiac status and structural anomalies
*X-ray chest – cardiomegaly, vascular prominence
*Cardiac catheterization - rarely

12. Requires-
*High index of suspicion
*Timely diagnosis (obtain history &identify risk factors)
*Effective management
*Team Approach-
*Obstetrician *Cardiologist *Anesthetist *Neonatologist *Nursing Staff
-Preconceptual counceling
*No pregnancy unless must esp in high risk types
*Optimal Medical/Surgical treatment pre-pregnancy
*Counselling-
*Maternal & Fetal risks
*Prognosis

13. *Clear counseling of risk and prognosis
*ANC every 2 weeks upto 30 weeks then weekly
*On each visit-note-pulse rate, BP, cough dyspnea, weight,
anaemia, re-evaluate grade of heart disease.
*Ensure treatment compliance
*Exclude fetal congenital anomaly by USG and fetal ECHO at 20
weeks in maternal congenital heart disease
*Fetal monitoring

14. *Rest, Avoid undue activity.
*Diet/ Iron and vitamins
*Hygiene, dental care to prevent any infection
*Dietary salt restriction (4-6g/d)
*Early diag and tmt of PIH, infections.
*Early admission to hospital ,grade 1 : 2 weeks
before EDD ,grade2 : 28 to 30 weeks and
emergency admission in develop of
complication.

15. -Nursing management for patients with Class III or IV heart disease.
*patients with grade III heart disease should not leave the hospital
until they reached grade I.
*Grade IV patients should not leave hospital at any time until after
delivery.
*The patient may need to be hospitalized for digitalis therapy:
-The nurse should take apical pulse for a full minute before administration of digitals
pulse < 60.
-Check cardiac monitor for arrhythmias.
-Observe for hypokalemia.
-Provide foods high in potassium
***Digitalis action :increase the force of myocardial contractions- produce a slower
and more regular apical rate

16. Monitoring of maternal and fetal well–being
-Assess maternal, pulse, respiration greater than 25/min,
requires careful evaluation to detect early signs of
complication.
-Monitoring maternal contractions (avoid bearing down as
venous return)
-Electronic fetal monitoring.

17. Implementation of supportive therapy
-Use of prophylactic antibiotics on doctor's order.
-Oxygen by mask if dyspnea occurs.
Administration of :
-Diuretics : to decrease the venous return to the heart and
thereby decrease the pulmonary and left atrial blood pressure
so reducing pulmonary congestion.
-Sedatives: help to alleviate anxiety and decrease the
voluntary muscle activity during the second stage of labor.

18. Reduction of physical exertion during vaginal delivery
•Encourage relaxation and sleep between contractions.
•Support the woman emotionally to be less anxious.
•If pushing in 2nd
stage, use shorter more moderate breaths, open
glottis pushes with complete relaxation between pushes .
•Monitor vital signs closely/10 min during the second stage.
•Oxytocin is contra-indicated in 1st and 2nd
stage.
•Blood loss during 3rd and 4th stage of labor is kept to a
minimum by prompt delivery of the placenta and oxytocin
administration – ergometrine is contraindicated lead to
vasoconstriction and hypertension so increase myocardial

19. Promotion of recovery
•Monitor vital signs regularly ,administer sedation and
antiobiotic .
•Maintain the woman in semi-fowler's or sitting position.
•The woman resumes activity gradually and progressively.
•Facilitate bowel elimination by controlling the diet.
Provision of psychological support
•Give the woman opportunities to discuss her birth
experience.
•Encourage maternal/fetal attachment.

20. • Postpartum hemorrhage, infection, and thrombo-embolism can
all precipitate crises and must be prevented or immediately
treated.
• Education and assistance in newborn care:
- A woman with grades I and II heart disease can breast feeding
her infant.
- The nurse can assist the woman to a comfortable side-lying
position with her head moderately elevated or to a semi-
fowler's position.

21. - Advice at time of discharge:
*Continue medical treatment
*Avoid infection
*Reassesment after 6 weeks or earlier if some complication
occurs
*Iron supplementation
*Cardiological consultation for definitive management of heart
disease
*Advice about contraception (Contraception- Barrier,
Progesterone – good option) COC - contraindicated